The Joint Commission’s 4-1-1 Survey Enhancements on High-Level Disinfection & Sterilization
By Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT
In September 2018, The Joint Commission (TJC) publicized an improvement to their surveys, calling it 4-1-1 on Survey Enhancements. These enhancements will be part of their on-site surveys for hospitals, critical access hospitals, ambulatory care, and office-based surgery facilities.
The Joint Commission surveyors will now take a deeper look at four high-risk areas that pose the greatest risks to patients if there is a failure. The four areas they are instructed to take deeper dive into are:
- High-level disinfection (HLD) and sterilization
- Sterile medication compounding
- Suicide prevention
I am not surprised that the 4-1-1 on Survey Enhancements includes HLD and sterilization as one of the four areas highlighted. The Joint Commission’s infection control (IC) standard IC.0.02.01 requires healthcare facilites to reduce risks of infections associated with medical equipment, devices, and supplies. This IC standard is one of the most regularly scored standards for noncompliance, which can put the patients at risk for an infection transmission.
The Joint Commission survey enhancement revisions are focusing on most all of the processing steps that pose the highest risks of infection transmission to patients if they fail. These survey enhancements began at the beginning of September 2018. The emphasis seems to be on ensuring healthcare organizations follow the evidence-based guidelines, such as those published by the Association of periOperative Registered Nurses (AORN), the Association for the Advancement of Medical Instrumentation (AAMI), the Centers for Disease Control and Prevention (CDC), and the Association for Processionals in Infection Control and Epidemiology (APIC), and strictly adhere to the manufacturer’s instructions for use.2 Historically, numerous organizations were cited for things that were the interpretations of the particular surveyor.
The 4-1-1 publication now describes how TJCpreviously cited a facility if there was visible bioburden and dried blood found on instruments. In addition, they used to cite an organization if an enzymatic solution was not applied to contaminated instruments to keep them moist. Nonetheless, that is not particularly what the current AORN or AAMI guidelines recommend. I am glad to see the new TJC scoring would only happen if the facility did not have a process for keeping contaminated instruments moist. That is clearer and does not mandate the use of an enzymatic solution. Now TJC states that surveyors will score if “wiping/flushing of soiled instruments is not observed during a case in the operating room or procedure room and it is clinically appropriate.”1
A further new guidance in the 4-1-1 is on transportation of contaminated instruments. Historically, the surveyors would cite a facility if any instruments were not transported from point-of-use in a leakproof, puncture-resistant container with the biohazard symbol or color red. Now TJC makes it clear that nonsharp items may be transported in a way that does not lead to contamination of staff or others; however, they still need to be in a biohazard-labeled or red container according to Occupation Safety and Health Administration (OSHA).1
In the past, TJC cited a facility if endoscopes exceeded a storage hang time. Now they say organizations must follow the manufacturer’s IFU for drying and frequency of reprocessing. The 4-1-1 now states they will notroutinely score findings related to endoscope hang time. If your hospital policy states a specific endoscope hang time, they will still score it if you are not following your own facility’s policy.1
I believe TJC is headed in the right direction with these new 4-1-1 survey enhancements, especially on HLD and sterilization. I think facilities may be cited less, particularly if surveyors are trained to all the new TJC expectations and current regulations and standards from our professional organizations, such as AORN, AAMI, CDC, and APIC. I recommend that all sterile processing, operating room, infection prevention, and office-based surgery professionals familiarize themselves with these new scoring guidelines if your facility is accredited by TJC.
- The Joint Commission. 4-1-1 on Survey Enhancements: New scoring revisions for IC.02.02.01 now in effect, posted 9/5/2018. Accessed 7/30/2019. Available at https://www.jointcommission.org/issues/article.aspx?Article=G%2FxUdh%2FVKujxJ12FY7q2i0ousSBZsyucrGSdk%2BHj1O8%3D
- Garcia-Houchins, S. Disinfection and Sterilization: Dispelling the Myths, Webinar. Available at: https://www.jointcommission.org/disinfection_and_sterilization_dispelling_myths/. Accessed 7/30/2019.
Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT, is president/CEO of Seavey Healthcare Consulting and formerly the director of the SPD at The Children’s Hospital of Denver. Rose served on the AORN board of directors and is a past president ASHCSP. She received numerous awards and was named as one of the Who’s Who in Infection Prevention by Infection Control Today. Ms. Seavey is the author of Sterile Processing In Healthcare Facilities: Preparing for Accreditation Surveys, published by AAMI. She serves on several AAMI committees helping to write national standards.
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