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New Scoring for High Level Disinfection and Sterilization

Tuesday, October 30, 2018   (0 Comments)
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October 30, 2018, Joint Commission Ambulatory Buzz blog, via ASCA News Digest  


High-level disinfection (HLD) and sterilization lapses are an area of great concern for The Joint Commission. The problem is especially pronounced in ambulatory health care (AHC) organizations, as 79 percent of AHCs and nearly 81 percent of office-based surgery centers (OBS) practices surveyed in 2017 had at least one finding in the infection prevention and control chapter.

After a careful evaluation of HLD and sterilization process steps, The Joint Commission has refined its scoring as of September 1, 2018 to focus on the process steps that pose the highest risk to patients if they fail. We are refining some of the scoring guidelines to clarify expectations. Earlier this month, I blogged about the impact these high level disinfection and sterilization breaches are having in all areas of health care.

These revisions are the focus of the latest 4-1-1 on Survey Enhancements — a Joint Commission blog series that takes a deeper look at four high-risk areas that are evaluated by Joint Commission surveyors. Other area of enhanced focus include:

  • suicide prevention
  • hemodialysis
  • sterile medication compounding

While our enhanced effort at surveying for HLD issues occurs at all accredited organizations, our surveyors are commonly noticing/scoring these issues in ambulatory care and office-based surgery centers.

In AHC and OBS organizations, the most problematic standards include:

  • IC.02.01.01 EP2 Standard precautions
  • IC.02.02.01 EP2 High level disinfection/sterilization

Standard Precautions
By and large, the single most frequent standard precautions findings are related to hand hygiene. Standard precautions that all health care facilities should follow can be found in the Centers for Disease Control and Prevention document Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee.

Key areas addressed in this document include:

  • hand hygiene
  • environmental cleaning and disinfection
  • injection and medication safety
  • risk assessment with use of appropriate personal protective equipment (e.g., gloves, gowns, face masks) based on activities being performed
  • minimizing potential exposures (e.g. respiratory hygiene and cough etiquette)
  • reprocessing of reusable medical equipment between each patient and when soiled

High risk findings related to this standard include:

  • use of single dose medication vials on multiple patients or availability for use after opening
  • taking a multi-dose vial into a patient room and then using it for a subsequent patient neglecting to scrub the hub of an IV line or medication vial
  • failure to provide or use personal protective equipment in locations where exposure could occur
  • failure to perform hand hygiene
  • failure to follow aseptic technique

Any IC.02.02.01 findings on survey before September 1, 2018 will not be removed. Organizations that are in the 10-day clarification window or that are preparing their Evidence of Standards Compliance (ESC) report should document compliance based upon the refined scoring guidelines.

We want the survey process to be as transparent as possible and hope that scoring refinements will help ambulatory organizations and office-based surgery practices focus their efforts on keeping patients safe! 


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