Joint Commission Citing Observations of Hand Hygiene Noncompliance, Effective January 1, 2018

PUBLISHED: Dec 26, 2017
Relevant to: Ambulatory Care, Behavioral Health, Clinical Lab, Community Mental Health Centers, Critical Access Hospitals, Dialysis Facilities, Home Health, Hospice, Hospitals, Long Term Care, Medical Office, Pharmacy

Beginning January 1, 2018, The Joint Commission (TJC) will begin to cite any “…observations by surveyors of individual failure to preform hand hygiene in the process of direct patient care…”

This new survey process is applicable to all accreditation programs.

Observations of hand hygiene failures in the process of direct patient care will be cited as a deficiency and result in a Requirement for Improvement (RFI) under standard IC.02.01.01, EP 2. Organizations are also responsible for (and TJC surveyors will also continue to survey) compliance with National Patient Safety Goal NPSG.07.01.01.

  • IC.02.01.01, EP 2 requires organizations to use standard precautions, including the use of personal protective equipment to reduce the risk of infection.
  • NPSG.07.01.01 requires organizations to comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.

Historically, (except for Home Care and Ambulatory Care Accreditation Programs) organizations have not had individual failures of hand hygiene performance cited, so long an organization was able to demonstrate a hand hygiene program with progressive compliance rates. However, since organizations have now had over a decade since the inception of the hand hygiene NPSG, TJC has determined that sufficient time has passed for personnel training programs to be firmly established.

Joint Commission acknowledges that there are many reasons for health care acquired infections, but they have determined that, “failure to perform hand hygiene associated with direct care of patients should no longer be one of them.”

Included with today’s notice is the TJC update on citing observations of hand hygiene noncompliance as well as several example policies related to hand hygiene.

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