Overview

The ninth chapter of the Joint Commission on Accreditation of Healthcare Organizations' Standards for Behavioral Health Programs is entitled, "Surveillance, Prevention, and Control of Infection (IC)." The goal for this function is to assure that the risks for acquiring and transmitting infections among clients, staff, contract workers, students, volunteers, and visitors are identified and reduced wherever possible. These standards apply to the entire scope of services in all program settings. The program must enact strategies to prevent in some cases—and minimize in all cases—the potential for the occurrence of communicable disease. If a communicable disease(s) is identified within the program setting, all efforts to prevent the transmission of disease must be instituted. This function includes all of the activities associated with the surveillance, prevention, and control of infections that are either acquired within or brought into the program. Specialists in the field of epidemiology must direct the program and oversee the infection control activities.

Accreditation Requirement(s)

To conform to the infection control standards, the program must show evidence of the following:

• Assessment of risks for acquiring and transmitting infectious agents within the program
• Incorporation of the infection control program into the client safety and performance improvement programs
• Strategies for identifying communicable disease through surveillance, data collection, and data analysis
• Monitoring of prevention activities, including immunization against communicable diseases
• Standards to address the minimization of transmission of the disease once identified
• Coordination with community leaders and organizations to identify and control the spread of communicable diseases in the community
• Implementation of the CDC Hand Hygiene Guidelines, sections 1A, 1B, and 1C (www.cdc.gov/handhygiene/)
• Education of staff on Occupational Health and Safety Administration (OSHA)—bloodborne pathogen information, use of personal protective equipment, handwashing techniques, and the requirements for reporting communicable diseases

Sample P&Ps

CDC Hand Hygiene Fact Sheet Policy and Procedure (DOC | HTML)
Coordinated Infection Control Plan Policy and Procedure (DOC | HTML)
Hand Hygiene Policy and Procedure (DOC | HTML)
Reduction of Endemic and Epidemic Infections Policy and Procedure (DOC | HTML)

Implementation Tips

• Infection control practices cover a wide scope of activities, including clinical practice, staff interaction with clients, and overall environmental cleanliness.
  
  
• Install alcohol-based hand rub dispensers at each sink in the program.
  
  
  • Teach staff about the situations in which the use of soap and water is required versus times when use of alcohol-based hand rubs is appropriate.
    
    
• Prohibit the use of acrylic or artificial nails for all direct caregivers.
  
  
• Make sure that all members of the program are aware of the significance of adhering to good infection control practices and can discuss their rationale if asked by management staff or accreditation surveyors.
  
  
• Stay abreast of JCAHO's National Patient Safety Goals (NPSG) related to infection control. This topic is a focus area for current surveys and will continue to be a priority focus area in the future. The NPSGs are updated and published each July for implementation the following January, so make sure that you are aware of any new requirements related to infection control.
  
  
• Reference the Centers for Disease Control and Prevention (CDC) guidelines for healthcare workers, other CDC publications, and fact sheets, and distribute the information to staff. Ensure that staff have an opportunity to discuss these guidelines and clarify their intent, if needed.
  
  
• After educating staff, contracted licensed independent practitioners (LIPs), students, and volunteers on your infection control policies and procedures, conduct "spot" audits to assure compliance, particularly with handwashing and use of personal protective equipment. Give 1:1 feedback to those who do not comply.
  
  
• Conduct environmental rounds to assure compliance with cleanliness and safety standards (e.g., sharps containers not overfilled, hazardous waste containers appropriately covered and labeled, gloves accessible in each treatment room, etc.)

References and Links

Guidelines for Environmental Infection Control in Health-Care Facilities
www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

Centers for Disease Control and Prevention, National Nosocomial Infections Surveillance System
www.cdc.gov/ncidod/dhqp/nnis_pubs.html

JCAHO Sentinel Event Alert #28
www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_28.htm
l+event+alert/sea_28.htm

Association for Professionals in Infection Control and Epidemiology (APIC)
www.apic.org/

Society for Healthcare Epidemiology of America (SHEA)
www.shea-online.org/

Infectious Diseases Society of America (IDSA)
www.idsociety.org/

Centers for Disease Control and Prevention, The Impact of Hospital-Acquired Bloodstream Infections
www.cdc.gov/ncidod/eid/vol7no2/wenzel.htm

Joint Commission on Accreditation of Healthcare Organizations: National Patient Safety Goals
www.jointcommission.org/GeneralPublic/NPSG