The Pulse | Thursday, April 9, 2020

Revising Your Infection Prevention Policies? Remember These Basics

In the wake of the COVID-19 pandemic, many hospitals and health care settings are reassessing and revising their infection prevention and control policies. In a time of uncharted crisis, it’s easy to feel unsettled and uncertain. And with so many points of references which guide our practice, it can be challenging to determine how best to approach the revisions needed.

The following is a figure provided from the Joint Commission, showing the hierarchical method to follow when seeking resources to inform your policies.

Hierarchy of References to Use When Drafting and Revising Infection Prevention and Control Policies, Per the Joint Commission

 © Joint Commission Resources, Inc.: "Clarifying Infection Control Policy Requirements." Perspectives Volume 39, Issue 4; P. 15, 2019. Reprinted with permission.

Additionally, SGNA spoke with representatives of the Joint Commission — Director of Infection Prevention and Control Sylvia Garcia-Houchins, MBA RN CIC, and Associate Director of Standards Interpretation Diane Cullen, RN MSN MBA CIC — to receive answers for two questions that often need clarification. Their responses are as follows.

Does the Joint Commission validate manufacturers’ instructions for use?

The Joint Commission surveys the organization’s processes related to disinfection and sterilization. It is our expectation that organizations have a process in place to validate that their choice of medical devices meet their requirements for intended use and that reprocessing of the device is based on FDA regulations, state requirements, CMS requirement if applicable, manufacturer instructions for use, and, if applicable, evidence-based guidelines.  

Does a facility need to follow the entire standard or can they just follow part of it?

Some organizations are required to follow a particular evidence-based standard because it has been incorporated by reference into their state licensing requirements. In those instances, organizations should contact their state licensing agency to determine if there have been any exceptions made. The Joint Commission would survey to the state’s requirement. If there are no state requirements, the Joint Commission would expect the organization to have done an evaluation of their chosen evidence-based guideline(s) and determine those parts that are relevant to their practices.

 

For more practice resources, visit SGNA’s Position Statements and Standards page, as well as the new COVID-19 Resources page.