The North Carolina Statewide Program for Infection Control and Epidemiology (SPICE) requested that North Carolina healthcare professionals in infection control send us a list of questions asked in their recent Joint Commission (formerly JCAHO) surveys to compile as a resource. New information will be added to this page as we receive it.

At last week’s Joint Commission inspection they looked at the following in Infection Control:

• Infection Control Plan and Risk Assessment-looked for local statistics and data, relationship with outside agencies, prioritized risks. They were happy with what we had which was basic but tailored to our facility.
• They wanted a verbal or written review of the last two years interventions and program related to hand hygiene - not just the data points for compliance.

Overall:

• Did not look or ask anything related to Employee Health this time.
• Asked for the copies of the written notification to the medical staff of their individual roles in a disaster under Emergency Management; that they had received it and returned a statement that they knew their individual roles.
• Wanted to see more detailed descriptions of the Emergency Management Contingency Plans – wanted them specific to how many gallons of water you had, for example, for how many people, for how long, where they are stored, how they are rotated, who is in charge of that….wanted to see specific roles for positions in the facility, at least the first five people or steps for each contingency plan – were not interested in seeing the command system on the computer for disasters but “want to see what you have and do in writing”
• Asked how the All Hazards Risk Vulnerability was done, how often – committee, consensus, one person – we had a community team and they liked that.
• Liked the nursing care plans but said they did not “go far enough”….wanted to see more depth and more individualization….”go the next step”
• A few things fell out on the medical staff, mostly peer review things
• Observed an OR case for an hour
• Observed in Central Sterile Supply for 30 minutes the processing of instruments
• Focused one tracer on an isolation patient, looking for compliance and documentation of teaching, so forth

Two very good surveyors who were more about teaching best practices, sharing ideas, than anything else….

The ICP who gave this report on the Joint Commission survey provided two forms to assist other ICPs.

• Infection Control Annual Plan
  
• Infection Control Risk Assessment

We checked the Joint Commission Website at 7:30 AM and there we were. We had been expecting them as we were due anytime after October 2007. We had two surveyors for 4 and ½ days.

The first morning they requested all my surveillance and IC meeting documentation for the past 12 months.

They also requested the IC Annual Plan and Risk Assessment. They suggested we use a graph to do our risk assessment instead of narrative format. But they complimented our Risk Assessment and Plan.

The IC tracer went very well. The surveyor asked for any patient in house who was on isolation or had a HAI infection or resistant organism. I provided three patients and they chose one. The surveyor (a nurse) checked admission orders. The patient had a history or MRSA and our policy requires isolation on admission if no negative cultures post identification. She was very pleased that our policy stated the nursing staff had the authority to isolate and culture patients. We had physician representation at our IC conference and tracer. She was very pleased about this. She went into the room and spoke with the patient. We received a very favorable report regarding Infection Control at the exit conference.

In other areas here are some of the things they asked or noted. How many non-English speaking patients we had. How did we communicate with them?

In tracers, they asked patients what each arm band meant and if the nurse checked it each time prior to giving meds or treatments

Wanted to see how pain control was documented on non-communicative patients. Pain must be assessed and documented. N/A or Non-responsive is not acceptable.

Checked to make sure all refrigerators with meds had temperatures checked twice a day.

Looked for evidence of competencies on staff doing 1:1 and suicide watch with patients.

Treatment plans were not patient specific enough. Ex. One plan stated that patient would calm down if provided a soda. They said we should be specific if it was Pepsi, Coke etc.

They did find some doors propped open

Make sure all of your med carts are locked. Some of ours are very delayed in the automatic lock and they found one open which was an automatic RFI.

They were big on Advanced Directives. Must document that patient was asked and if they had one; they wanted to see it on the chart or documentation as to why it wasn't there.

Questioned when physicians signed standing order.

Looked for indications for PRN meds. Wanted specific reasons why to administer.

Looked at amount of time between when a dietary consult was ordered and when it was done.

They did visit our newly acquired physician practices.

They looked at medication reconciliation sheets. Especially if a patient was coming in from a private office.

We had a table top exercise to test our Emergency Management Plan. Luckily we had a drill in December which was almost identical to the synopsis they provided. This went very well. They were big on disaster preparedness and planning.

I can say this was the easiest most relaxed survey in which I participated. I loved the tracer method and so did our staff. I think being unannounced was good. They really saw what our normal routine is like.

February 2007

Infection Control topics discussed during joint commission survey:

• They asked a CNA, What is your policy for cleaning and hand hygiene when caring for a patient with C-diff?
• We also had a sudden increase in the number of patients we were admitting with possible Norovirus and they were very interested in how we were handling these patients - including isolation, staff education and observation for compliance. The IC tracer was done on a pediatric patient with Norovirus, which was really to our benefit. Staff were interested in the recent education IC prepared on Norovirus due to seeing other hospitals on the news and the concern for themselves and their own family members.
• They asked staff how long they were suppose to wash their hands and when staff gave correct answer, surveyor asked how they measured the time.
• Looked over the IC risk assessment and Surveillance Plan, asked questions about how risks were prioritized.
• What has IC done in the last year to improve patient outcomes and who was involved in the process improvement.
• They observed employees throughout survey for compliance with isolation precautions and hand hygiene.

North Carolina Specialty Hospital had its first JCAHO Accreditation visit September 12-14, 2006. We received no recommendations and just one supplemental. Although we had a plan in effect related to the supplemental the Reviewer wanted to see a written policy. We now have such a policy entitled "EMERGING COMMUNICABLE DISEASE (ECD) INFLUX POLICY."

October 26, 2006

Since we are critical access, we only had one surveyor. The following is what he asked for from me.

• All volunteers' health files (wanted to see same stuff in these as employee files).
• Infection Control(IC) Plan for Surveillance - wanted to see priorities of pathogens and evaluation plan of strategies. Wanted everything in JCAHO standard language. IC Standard for Plan of Surveillance and has 4 parts. He wanted to see the use of their "buzz" words in that standard.
• Plan for influx of large numbers of infectious patients and had we drilled on it.
• Handwashing inspections and rates (we do two types, observed and self-reported); he was impressed with this and didn't mind our rate of 77%; also wanted to see our policy but never looked at it.
• Wanted to know our physician compliance with hand hygiene and which department was the best at it.
• Asked a lot of questions about our surgical site infection surveillance process and our surgeon compliance with that.
• Medical Staff health files (picked one member of our medical staff and they are NOT hospital employees so we had only TB skin test; he did not like this; wanted to see vaccinations etc., like employees)
• Pulled an agency nurse file and was not happy that TB and vaccine history not in the file.
• Asked about our surveillance methods and what we looked at (we look at ALL cultures and ALL infections because we are so small)
• Asked about our statistical calculations given our small size
• Asked for evidence of community work but never looked at it; seemed happy enough with talk about working with doctors' offices, schools and the local health department
• Wanted to be sure I had enough resources to do my job; said he'd make a recommendation if I needed anything!
His background was OB/GYN surgery.

Unannounced JCAHO survey

At Cape Fear Valley Health System, Fayetteville, NC we were surveyed by an unusual physician surveyor the first week of April. Dr. Marion Snowden was the physician surveyor. She is originally from New Zealand and currently lives in Arizona. Although her personality is very amiable, her pin is mighty! Comments heard at daily briefings were thought to be suggestions/recommendations, but ending up on the final day to scores of zero. She stated that she was on a mission for Infection Control and boy was she! We received a Requirement For Improvement (RFI) for IC.4.10, Elements of Performance 1, 3 and 4. Most of this was from her findings related to mixing of clean and "dirty" items. She did not want to see any reusable equipment mixed in with individually packaged sterile or clean patient care items. Example, stethoscope or pen organizer next to packed sterile syringe. She did find some clearly incorrect things such as dating of high level disinfection minimum concentration test strips (should be dated 90 days after opening the bottle), a staff nurse told her she used a container of applesauce for patients with difficulty swallowing for multiple med passes during her shift and an Anesthesiologist gloved hand carried a contaminated TEE scope back to the TEE Lab.

The other surveyors had findings too which were legitimate. The area were Anesthesia Techs reprocessed laryngoscope blades was crowded and multi-purposed. Uncovered linen and open rack bottle shelf on the linen cart in the sterile core. Contracted in-patient hemodialysis unit/staff took the transparent dressing off of a central line which was placed the day before and left the site uncovered while the patient was receiving dialysis. The patient's gown touched the site.

We appealed several of our other RFIs, but I could not appeal this RFI. I am having to submit an Evidence of Compliance report for IC.4.10. This was very difficult to come up with a plan that would prevent storing reprocessed items with packaged items. We developed a very laborious process where daily checklists are done on seven areas (medication cart on wheels, med room, nourishment room, clean utility, equipment storage, soiled utility and nurses' station). These are turned in monthly to IC. We compare the results with our inspections and requests action plans when there are issues.

We completed our survey last Friday 02/25/05 . It was very interesting as we had the surveyors for 4 and 1/2 days and usually it is 2 1/2 days.

Here is a list of questions/points of interest and comments regarding Infection Control

• They were impressed with our handwashing signs. On two occasions they observed visitors washing their hands prior to entering rooms and were impressed with that.
• They asked about our physician's participation in Infection Control. Since we do not have a hospital Epidemiologist, they wanted to know what outside resources we used. I told them about SPICE, and APIC and that Pitt Memorial was always willing to help us out.
• They wanted to know how we measure our success in reducing hospital-acquired infections. They were interested in how we get our benchmarks. They were impressed when I told them about the SPICE benchmarking project (Small Hospital Infection Surveillance Study - SHISS) and that we are participating in it.
• They were interested in how we do our post surgical surveillance. They liked our system and wanted to know what rate of response I get from surgeons. Fortunately our surgeons are very good and prompt in the return of data.
• In our systems tracer with the IC Committee, they talked a lot about Antibiotic use. They were interested in how physicians were notified of sensitivities.
• They asked what measures we had in place to prevent hospital acquired pneumonia in stroke victims.
• They asked about our flu vaccination program and surveillance of employees who received the vaccine and contracted the flu.
• They checked each nursing unit for our handwashing monitor sheets.
• We did well in Infection Control.
• They really were less document focused. They like charts and graphs though. They want to see what you change or do different in response to the data you collect.

The infection control part of the survey November 8-11 was a good one for us. I had nothing written up. We had blitzed the hospital with hand hygiene information. The week prior to the survey I put up a poster at the time clocks on Preventing and Controlling Infections and Standard and Transmission-Based Precautions with an infection control compliance survey with the answer key. Our staff did very well when asked questions and were observed using proper hand hygiene. The surveyor asked for all surveillance data for the last 12 months.

Some of the questions asked included:

• How do you know when to put a patient on precautions and is an order needed to put them on isolation?
• How do you plan to use the 2005 standards in your infection control plan for 2005?
• What type of surveillance do you do? What benchmarks do you use?
• What types of outbreaks have you had?
• Who is on your infection control committee? How do you utilize these persons?
• Who monitors the hand hygiene and how?
• What types of surveillance, other than infections, are you doing?
• Have there been any areas of concern for possible infections in the last year such as construction and what did you do about it?
• How are you doing with the Core Measure of giving the pneumococcal vaccine to patients and what have you done to address this issue and any other Core Measure issues? The surveyor talked about the importance of working together on the surgical site infection core measures which we began with July discharges.
• The surveyor asked the managers if they received reports from infection control.
• The surveyor asked about how information systems supplies us with the information we need and what data we used in infection control.
• The surveyor asked about bioterrorism and how we interacted with the community.
• The surveyor asked what type of foreign born population we were dealing with.

Received July 2004

• How was your IC Program developed?
• Who is represented on your IC committee?
• Do you monitor all infections in your hospital?
• What is the most prevalent infection seen in your hospital? How is it addressed?
• What do you do with the information (re. infections) you gather?
• Where do you get the data (re: infections within the hospital, nosocomial and community acquired)?
• How is this information disseminated?
• How is the IC Committee involved with the Child/Adol immunizations?
• Do you have a policy that addresses how to manage child/adol who do not have an immunization record or are unable to provide an IZ record?
• What hand hygiene training is provided to staff and patients?
• Is there a competency for hand washing/use of alcohol agents?
• Is hand hygiene a part of the child/adol program? How monitored?
• Do you have a Pet policy? They asked to see the policy.
• Do you have copy of the pets' immunization record? (We have a pet therapy program.) They asked to see the immunization records.

These are a few of the questions that I can remember that were asked by the surveyors. They wanted spontaneous answers. They had already looked at the IC Committee minutes, monthly reports, graphs, PI reports etc. before the IC session. The IC session was on the last day of the survey so the surveyors had visited all areas of the hospital and had a good idea of what the IC issues were prior to the IC session. Our IC department did very well.

Surveyed July 2004

Questions from the nurse surveyor in the systems tracer for the infection control committee were:

• What are you doing for the 2005 standards?
• What is the makeup of your infection control committee?
• What preventive efforts are you doing in employee health?
• What questions do you ask on your employee medical assessment? Do you
• ask about varicella?
• Do you have a competency assessment for drawing blood cultures?
• Do you have much aspiration pneumonia? Do you do a competency assessment for the evaluation and care of patients with swallowing problems?
• What are you doing about the OSHA alert for latex?
• What pathogens are you most concerned about in your facility?
• What are you doing for respiratory hygiene/cough etiquette?
• Are you doing hand hygiene surveillance and are you teaching your patients hand hygiene?
• Tell me about your hospital surveillance.
• Asked about our methods for control of legionella and mold

Surveyed June 2004

Largest Hospital in the System Infection Control Interview

• What are we doing to reduce infections
• What type of Infection Control projects or activities have you been involved in
• Surveyor discussed importance of looking for best practices and contacting hospitals that had made improvements
• Surveyor also went into a long discussion on preventing infections in donated organs and with organ procurement, our pathologist was able to say that organs that are harvested are looked at by the pathologist. We do not do transplants.
• What unusual organisms have you had
• How do you report to the Health Department and what/when etc.
• Bioterrorism preparedness and decontamination - wanted to know what we had done to prepare and use of the grant money
• How is infection data presented up and down in the institution (like the fact that we had a Board member on the Infection Control Committee and that she attended this interview - Board member was able to discuss how information on infection control is disseminated through the organization.)
• Medical Staff involvement and Infectious Disease involvement and coverage - discussed with doctor present at the interview
• Handwashing compliance and how that is monitored

Infection Control issues they were concerned about:

• Charts when patients are transported to other depts. are put on the bed or tucked under the mattress. I explained that we had investigated this issue and could not come up with another alternative for the charts since many patients are transported in their beds. So charts are considered dirty items and staff including secretaries on the units have alcohol hand rinse available when handling the charts. They were fine with this answer.
• Concerned about some supplies being stored on a bottom shelf that was not solid but was a wire rack. Showed them the AAMI standards which state 8-10 inches off the floor. Shelving was 8-10 inches off the floor so they were ok.
• Were concerned about chemicals (cleaning supplies) under the sink in a patient treatment area. Is an area where patients are located in the sleep lab for treatment, concerned that the patients may be left alone in that area and there were cleaning supplies under the sink that the patients could have access to. Did write up as a supplemental recommendation for Hazardous Materials. There were no patient supplies under any sinks, but they did not like the cleaning products there either if there were any patients in the area.
• They did trace a patient with MRSA infection and looked at isolation technique on this patient.
• They are very into the patient safety goals particularly patient identification, verbal order read back, and abbreviations.

Home Health and Hospice Infection Control Interview:

• How are infections monitored
• Do you feel you identify all of the infections
• Why are rates so low
• How are staff educated
• How are staff involved in data and infection collection and monitoring

Smaller Hospital with Long Term Care Infection Control Interview:

• Infection rates, how do you identify infections
• Prevention activities
• How and why are infection rates so low
• Number of infection control personal and hours worked (have corporate Infection Control Director and part time ICP still in orientation)
• Role of the laboratory in infection control
• Asked about most common organisms
• Discussed reporting and communication with the Health Dept.
• Use of alcohol foam and compliance monitoring
• How do you educate staff on infection control
• What are your concerns about the 2005 Infection Control standards
• Have you had any sentinel events related to infection control
• How many needlesticks have you had - why did you pick that for FMEA, should be proactive process. Stated that needlesticks were low - were being proactive to prevent all needlesticks if possible

• She asked for an overview of the program, and introduction to the staff/committee members present and their involvement with the hospital infection control committee and the department.
• She wanted to know how surveillance is done, how we tracked resistant organisms.
• She asked about sentinel events.
• She asked about the monitoring of infectious diseases (influenza, RSV) and what was done if there was nosocomial transmission.
• She wanted to know what kind of performance improvement we had done, accomplishments, etc.
• She was very interested in how well we worked in conjunction with other departments (safety, engineering and operations, pharmacy-antibiotic team, laboratory, etc).
• She wanted to know how the ICPs monitored for infections, the criteria we used and was impressed with our links with the lab, and that we could download labs from our office PC.
• She was interested in environmental rounds and construction, and how it was monitored.

Surveyed November 14, 2003
Surveyor: Ann Fonville

• How will the 2004 JCAHO infection control standards affect Infection Control at this hospital?
• What are the interventions you will put in place to meet those new issues? Who will the new process involve?
• Tell me about your surveillance.
• Where are your hot spots? What interventions did you use to reduce the risk of infections? Who was involved? Are you monitoring the changes?
• Tell me about your committee activities. Is pharmacy represented on the committee?
• Has Infection Control been involved with the implementation and installation of waterless hand soap?
• What is the latest news on regulation of the placement of the waterless hand soap?
• What about Bioterrorism? Describe the SARS event in NC. What did the ER do?
• How are you connected to the other authorities, your county and state, and the Health Department regarding Bioterrorism? How was triage and a decontamination area managed?
• Tell me about your employee health program. Do you have much TB in this area? Have you had any conversions in the last year? What percentage of your staff had their PPD last year? What are the major issues in employee health? Tell me about your flu vaccine initiative.
• Who takes care of the negative pressure rooms? How many?
• Have you had any outbreaks?
• Do you re-sterilize any single use devices? Which items?
• Tell me about any other initiatives related to infection control or patient safety.

The surveyor asked some of the following questions:

• Stressed prevention in this setting
  
• Asked about staff inoculations, ie: TB Flu Vaccine, Tetanus
  
• Toured facility, asked about waterless hand cleaners.
  
• Asked staff about blood spill kits, yearly Infection Control education.
  
• Asked about client education
  
• Asked about data gathering process
  
• Asked about referrals to area Health Dept, hospitals.
  

• How long had I been doing infection control?
• Was I certified in infection control?
• When was I going to be eligible to test for certification in infection control?
• Had I seen the info on Sentinel Events secondary to nosocomial infections?
• Had the facility had any deaths due to nosocomial infections?
• What types of things did I track or do surveillance on?
• Do I follow both inpatient and outpatient postoperative infections?
• How do you get information back from the physicians concerning post-op infections/SSIs?
• Do you have an Infectious Disease physician on staff?
• Who did I network with locally?
• Were they CBIC certified?
• Where do you refer patients to or consult with concerning infectious disease?
• Who is the chairman of the Therapeutics Committee and what is his speciality?
• Did I think that the aspiration pneumonia cases that we had were related to infection control issues?
• What is the biggest infection control issue/challenge at this facility?
• How were we combating MDROs?
• Looked at my graphics showing the MDROs numbers for 2001/02/03.
• How had I disseminated info on SARS to the physicians and staff?
• Were there any SARS cases in NC?
• Where did I get my SARS information from?
• Did I interact with the local county public health department infection control counterparts?
• How many negative airflow rooms do we have?
• Had we had any cases of TB as inpatients?
• Ever had any outbreaks that I had to track?
• Asked about prophylactic pre-operative antibiotic usage and trends.
• What did I hope to accomplish in 2003?

Here are the questions which were asked.

• If we had an Infection Control Committee, how it functioned, who voted. (recommended opening the vote to all members.... ours is a "Medical Committee").
  
• Same discussion ensued with our Authority Statement..... suggested we may want to include Infection Control Coordinator.
• Asked about what type of surveillance we were performing and why/how we chose what we did.
  
• Asked total number of surgeries.... how many outpatient vs.. inpatient.
  
• How we collect outpatient surgical data. What the MD response rate was. Asked if there were any infections.
  
• Questioned whether we separated nosocomial and community acquired MRSA and VRE. Asked if there had been an increase or decrease from 2001 to 2002. Questioned whether we were looking at the appropriate use of Vancomycin..... asked if MDs were aware of dosage protocols, how many doctors ordered what was not appropriate.
  
• Asked the percentage of employees that had taken a TB screen in 2002. What happened to the rest? Requested data to show what happened to the rest that did not do it. Asked if we had any conversions.
  
• Asked about splashes and needlesticks.... what were the numbers for 2002. What for 2001? Asked if we had had any exposure that needed follow-up for Hep. B.
  
• Asked what PI we were doing and let us run with that. In describing one PI project for central lines.... was questioned whether we had observed central line insertions in ICU, if we had criteria to assess line insertion, asked what we had done differently (rates went down). Questioned who established thresholds.

• What is your background?
  
• Tell me about the committee and committee meetings.  How often do you meet?
  
• No infectious diseases doctor on staff?
  
• What has your surveillance activity focused on in the last 24 months?
  
• What was the rationale for looking at the event?
  
• So you don’t have data to see if a difference has been made?
  
• You mentioned “handwashing technique” – please expound on this.
  
• Do you watch doctors wash their hands?
  
• Where else is the alcohol-based handwash available?
  
• Where in the nursing station?
  
• You mentioned antibiotics.  How does the committee help address the antibiotic problem?
  
• Are there any drugs that are restricted in their usage?
  
• Can vancomycin be ordered under any circumstances or certain circumstances?
  
• With so much out-patient surgery being done, how do you find out what your post-op infection rate really is?
  
• In current literature, there has been noted an increase of cross-contamination due to computer hardware.  Have you come across that?
  
• Have you had any fatal nosocomial infections?
  
• No sentinel events?
  
• Relay to me any construction challenges you have faced.
  
• Speaking to operating room representative: What do you decontaminate?
  
• What plans do you have for decontamination
  
• What involvement do you have with Employee Health?
  
• For clinical personnel, what are you doing about “nails”?
  
• What information do your employees have about blood exposures?
  
• For HIV text, how quickly do you get the results back?
  
• How and when do you start an exposed employee on prophylactic medications?
  
• Report on sterilizers?
  
• Going back to HIV, have you had to put exposed employees on drugs?  How were they exposed?

Questions asked:

• Do you have an alternative decontamination site?
• Tell me about your surveillance plan
• Tell me about your TB plan
• Do your doctors participate with PPDs
• How often do you do infection control rounds and with whom?
• What about your hazardous waste? 
• How and when do you educate your staff?  What about doctors?
• Have you addressed CDC's latest handwashing recommendations?

After that, then said JCAHO would be going back to the more specific Infection Control Standards which pretty much spell out what they want.

The physician was Dr. Joseph Skarzynski.

Surveyed February 2003

• What I monitor and how I benchmark (I do VAP, CL, FRUTI in CCU; Maryland Report Indicators, Physician compliance with Anit-biogram recommendations; Compliance with revised care of vent patients (CCU/CP staff compliance); Syndrome Surveillance thru ED; Compliance with Contact Precautions (just instituted new isolation carts and new method of keeping them stocked) and a yearly SWI Peer Report.
• Wanted to know how I monitor for infections ( I do all the usual things plus he was very pleased with my going to Interdisciplinary Meetings and the Infection Control Rounds I do plus 2 Focus Studies I did: hand washing vs sanitizing and a SWI outbreak in Class I procedures-we found a "smoking gun" and "disarmed" it).
• Asked a lot about our Disaster Drills - especially the simulated Table Top drill we did in Sept.-wanted to hear all about who all came-esp. the folks in the community (we had H.D. from 2 counties, Red Cross, FD, Police, EMS, clergy, Belinda Worsham from Regional Surveillance Team and several others + our managers/administration). Asked for details about how we would evacuate patients. Asked about Nuclear Disaster Drill-we plan to do with EMS in a few months and that was OK with him.
• Asked about problem pathogens. We have had an increase in MRSA even with stricter Contact Precautions (masks required late 2001 along with gloves and gowns if in resp. or external wound). The revised iso. carts are hopefully going to decrease this problem and he seemed impressed. (our biggest problem was that the carts just were not stocked with what HCW needed when they needed it) Liked the new hand sanitizer posters we just put up plus all the documented education for staff/docs/public regarding sanitizers, too.
• We used a lot of storyboards-old hat but still went over well. I used the term "safety" as much as possible-with patient/employee/physician/visitor responses.
• He wanted to see my SHARPS LOG for OSHA.
• Asked about EH new hire and annual requirements. Checked 15 files.
• Asked much on how Pharmacy monitors antibiotic use -then got off on a rabbit trail about monitoring control drugs. This took up most of the rest of my time so I was off the hook so I just coasted from there.

Surveyed January 2003

• How does your Infection Control Plan impact the population your hospital serves (outside the hospital)? He wanted to know what kind of IC problems existed in the community and how we addressed them with inpatients. Here he was looking to see that the ICP worked well with the Local Health Dept. to address community issues once patients were admitted and that the process was outlined in the IC Written Plan.
• How does IC impact STD's and communicable diseases in the community? This was a continuation of number 1.
• What kind of follow up is given for outpatient surgery patients? We do a 14 day follow-up survey, including questions related to infection. He recommended a 28 day follow up survey to include questions related to infection.
• Does someone monitor for inappropriate use of antibiotics? Where is it reported? He states that this data should be reported to the Infection Control Committee in addition to the Pharmacy and Therapeutics Committee.
• Who documents physician immunization records? He states that this should be recorded within the hospital.
• What is IC's role in construction? He liked the IC Risk Assessment Form.

Received January 2003

JCAHO Survey: December 3,4,5, 2002

Infection Control (IC) Interview: Coordinator of Infection Control/Employee Health, Director of Quality Management, Hospital President, Coordinator of Risk Management and Safety, Director of Surgical Services, Director of Environment of Care, Secretary (Note-Taker)

Infection Control:

• Ask what is the biggest IC issue at our hospital
• Asked if there is a group in the area that can be used as resource (I mentioned APIC - NC and regular zone meetings and the statewide IC program, plus individual practitioners in the area).
• Asked if we have an epidemiologist or a physician involved with IC on staff
• Asked what my specific responsibilities were
• Asked what educational activities I did for the employees
• Asked about hand sanitizers and the direction we are headed in with that
• Talked about the hand hygiene guidelines
• Asked if we had many problems with handwashing (We do a handwashing survey every year and then repeat it in departments that do not meet our goal - I reviewed the results with them).
• Asked if there were ever any trends that seem to be evident throughout the community
• Asked about my background, how I got into IC and how I was prepared to do this job
• Asked if we resterilized, recycled (We do not reuse single-use products).
• Asked what kind of required reporting was done and to whom
• Asked about any trends identified
• Asked what my position was on the Smallpox vaccine and if a policy would be developed on who gets the vaccine
• Ever had any outbreaks?
• Asked about IC issues in the operating room
• Are needlesticks a problem, and if so, are most of them contaminated
• What is the process that takes place when a nedlestick occurs
• Ask if we know of any HIV employees
• Asked Director of Environmental Services about staff turn over in his department
• Asked if housekeeping staff is exposed to needlesticks

Employee Health: (EH)

• Asked how I was involved in EH (I also am responsible for EH)
• Asked how occupational injuries were handled
• Asked about drug testing and if we do any drug testing for industries in the area (Not through EH)

Received November 2002

We had a 3 day survey in September 2002. It was quite different than previous surveys (we usually have 4 day surveys. The surveyors came back on the night of the first day and the focus was on security, infant safety, and Environment of Care (EOC). They visited the Obstetrics/Gynecology areas, Labor and Delivery, Nursery and Emergency Room.

Infection Control was interviewed on the last day of the survey for 45 minutes. The Environment of Care Interview was scheduled at the same time and Infection Control was requested in both interviews. EOC lasted 1 hour and 45 minutes. I also attended the Department Directors Interview and the Inpatient Dialysis Interview.

Infection Control Questions

• What are you doing differently since 9/11?
• Construction preplanning - are you the second person consulted or the 200th?
• Your surveillance is targeted- Why?
• PPD - annual rate of compliance?
• Compliance with physicians' PPDs?
• Members of the Infection Control Committee, is the chairman an infection diseases specialist?
• What is the newest safety device in place?
• Needlesticks - trends in departments?
• Surveillance- any trends in departments?
• Asked Employee Health what the latest policy change was.
• Asked about the varicella policy
• Antibiogram trends?
• Any antibiotics restricted?
• Any outbreaks?
• Fit testing employees, any employees converted to HIV or hepatitis?
• Are you using Epinet?
• Is personal protective equipment available?
• Are you using Cidex? Testing strips?
• Flu vaccine compliance?
• What did you do with the anthrax issue as far as educating employees?
• Do you test for Legionella?
• What is different this year on employee annual education?
• Authority statement?
• What PI projects are you working on?

Department Directors interview was heavy on bioterrorism, patient safety, and performance improvement

Dialysis interview was heavy on patient safety (what processes do you have in place to protect patients?)

Infection control questions addressed hepatitis in the dialysis patient and employees as well as water cultures.

Environment of Care Interview:

• 7 safety plans were addressed one by one - went over each one.
• Wanted to see performance improvement activities and wanted to see graphs. (We used sharps injury prevention).
• Do you test for legionella?
• Patient safety- how are you preventing MRSA and VRE?
• Bioterrorism - is there community involvement?
• What is infection control's involvement with construction? Wanted infection control involved at the start.
• On rounds, looked heavily for torn wallpaper and stretchers, and vent cleanliness.

Received April 2002

Infection Control Staff Preparations

Infection Control staff concentrated on areas JCAHO surveyors were scheduled to visit. Assignments were made to each staff member. Over the course of about 4 weeks (prior to the visit), Infection Control staff worked with individual nurse managers to make improvements:

• Separation of clean and soiled activities (e.g. splashguards, rearranging of activities, closed cabinets)
• Sterilization documentation
• Glutaraldehyde monitoring
• Refrigerator monitoring (improved temp documentation record)
• Freezer checks (e.g., loss of electricity)
• Expiration dates of supplies
• Education as needed
• Prepared written information re: infection rates/outbreak evaluations for each nurse manager (annual 2001)
• Prepared JCAHO checklist for all managers
• Ensured regulations implemented (e.g., safety devices, single use items not reused)

The Unit Based Survey

• Dating of multi-dose vials
• Bioterrorism preparation
• Responsibility/accountability of infection control weekends, evenings
• Performance Improvement projects - one surveyor discouraged use of improvement of infection rates as a Performance Improvement project. Patients expect good outcomes. He mentioned improving patient satisfaction scores would be better
• Infection Control nurse was asked how confidence intervals are calculated and how we benchmark

The Infection Control Interview

• Stated Department plan should include epidemiological issues of importance with respect to the patient populations served. Relate this to the scope of services
• Asked:

- how we identify strategies for the program
- type of surveillance performed
- Performance Improvements projects (was pleased they were linked to -the organization’s strategic goals).
- if needlestick data/analysis is discussed with departments
- what is the strategy to reduce needlesticks
- to see the nosocomial infections data
- what is the overall plan
- who we benchmark with
- what are you most proud of
- what education and other activities are done to prevent infection
- what preparations have been done re: bioterrorism
- about our involvement with clinics/community based centers (wants to see you are an integrated system)
- aspergillus infections in patients
- about credentials of staff

Overall Focus of JCAHO Team

• Patient focused especially re: patient safety
• Want to know the organization as a whole focuses on patient safety.
• Asked who is the one person responsible for patient safety
• Is the organization using aggregated data with analysis to make plans of action
• Staffing effectiveness indicators (spent time educating Nursing Leadership/Human Resources to new standard effective June 2002)
• Asked how the organization ensures competency of staff, particularly contracted staff such as travelers (JCAHO expects orientation, training, competency to be of equal value to regular staff)
• Very interested in physician involvement re: performance improvement
• Asked Department Directors to rate the organization on performance improvement. Discussed the scores (which varied widely).
• Asked each Department Director to state in one sentence what he/she was most proud of (looking for quality patient care)
• Interested in how narcotics were dispensed, where narcotic waste is collected; consents and history/physicals documentation; nutritional assessment of each patient
• Looked at crash carts to ensure policy is followed. Stated opened crash carts should be kept in a staff-observed area until retrieved for restocking
• Looked to see if verbal orders were signed (and dated)

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Received April 2002

Infection Control Interview

• Surveillance- What, Why, How Long
• Reaction to Bioterrorism/Terrorism
• Construction- Risk Assessment
• Home Health Surveillance- What and Why

- Benchmarks

• Involvement with Physician Practices
• Employee Health/Wellness
• Information Technology Support
• Facility Appearance
• Sidelines

- Proactive Culturing for Legionella and Other Bugs
- Cups of Ice in Freezers in Areas Not Open 24/7

Environment of Care - Building Tour - Looked at:

• Vents
• Ceiling Tiles Appearance
• Removed Ceiling Tiles for Fire Penetrations
• Linen Carts
• Under Every Sink
• Refrigerators
• Expired Meds/Supplies
• Construction Areas
• Fire Extinguisher Inspections
• Plant Operations
• Water
• HVAC
• Exits
• Lighting
• Interim Life Safety Measures
• Rooftop

Environment of Care - Interview

• Disaster Preparedness and Plan
• Sharps Log/Evaluation of New Technology
• Disaster Preparedness and Plan
• Construction Goals
• Dialysis Culture Reports
• Ventilation/ Air Exchange Rates
• Dates of Departmental Safety Inspections
• Safety Information- Dissemination

Endoscopy

• Assessment of Patient
• ASA Scores
• High-Level Disinfectant Choices
• Communication with Infection Control Professionals on Infections
• Follow-Up After Procedures

Operating Room

• Surgical Site Infection Surveillance
• Sharps Log
• Risk/Benefits of Surgery
• Medication Security
• Recalls
• Wrong Site Surgery
• Post Discharge Surveillance

Intensive Care Unit

• Ventilator Pneumonia Cases
• Types of Organisms Causing Infection
• Ventilator-Associated Pneumonia Rate
• Communication between Infection Control Professional and Unit
• Collaborative PI Efforts
• Restraint Usage

Human Resources - Documentation of:

• Immunizations/Employee Health Issues
• Competency
• Pay Attention to Physician Extenders and CRNA’s

Home Health

• Home visits with CNA’s and RN’s
• Watched everything! (from baths to blood drawing)
• Documentation, Documentation!
• Performance Improvement - Involvement with Infection Control Professionals on Indicators

General Comments

• Communication Between Infection Control Professionals and Other Departments Is Important
• Re-visit Your Data. How Long Do We Need to Keep Looking at Things?
• Be visible. Make Rounds.
• Patient Safety- Failure/Mode

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Received March 2002

The first day that JCAHO arrived at our hospital, the nurse who was the lead person of the survey team, asked for the infection control policy manual, infection control reports for the last year, and any infection control surveillance manuals that I might have.

The Infection Control interview was scheduled for the second day (45 minutes allotted). The Employee Health Nurse, myself (Infection Control Director), two infection control professionals (one from operating room and the other from coronary care unit) since I had only been in the position for two months, the hospital epidemiologist, and the Vice-President of Patient Services (who is a nurse) all attended the interview.

The nurse surveyor asked:

• How the infection control program was set up.
• What areas we did surveillance in and our findings.
• Any problem areas we have noticed - there were none; all of our surveillance activities were in control.
• Asked specifically about our MRSA rates and I had a graph to show her that we were not having a problem.
• Then she asked a lot of public health questions (thank goodness because I had just left employment at the health department as communicable disease nurse for 13 and 1/2 years and supervisor of communicable diseases, immunizations and adult health for 9 years there).
• She asked about tuberculosis (TB) patients and how they were handled in the Emergency Room and how the health dept is notified about a TB patient.
• How we handled TB patients in the hospital, i.e., isolation.
• Asked if the health department staff were welcomed into the hospital and how they fit into the care of the patient.
• Asked who in the hospital would be in charge of handling a suspected communicable disease. I told her that it depends on what the communicable disease was but that I would be assisting the nursing staff and also said that I would involve the hospital epidemiologist and the patient's physician and of course the health department if the communicable disease was reportable.
• She asked about employee injuries and the Employee Health Nurse addressed that issue and went into detail about our Employee Wellness Program. We have a gym, a pool, exercise classes, yoga, etc. We have back school for employees who injure their back on the job. They have to attend this school.
• The nurse surveyor asked what infection control projects we had done in the last year and the two infection control professionals answered that question and went into great detail.
• She had reviewed the infection control policies and liked them. Had a few questions about where to find certain things in the policies but when I showed her, she was fine with them.
• Overall, the infection control survey went great.

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Received March 2002

• We need to establish a rural hospital NNIS sort of thing so we can benchmark against each other (hospitals <100 beds) and determine where we stand with other hospitals with infection rates.
• She was concerned because we did not have a system in place where we received reports from our Plant Engineering on Cooling Tower maintenance and water supply maintenance to put in our safety and infection control minutes.
• We needed to have a log that showed our whirlpool was cleaned between patients.
• She was concerned with our storage of things on the floor; as usual we had several areas that still had things on the floor in spite of all my preaching.
• We have several doctor's offices and one dental clinic affiliated with the hospital. The dental clinic has a sterilizer. The autoclave spore tests were the type that took three days to determine if there was a sterilization failure or not. She thought that the results were taking too long and that we needed to use the more rapid testing method, although the recommendation still calls for weekly testing. Also, the log sheet that the clinic used to record those results needed to be included in the infection control minutes like our in-hospital autoclave reports are. She also wanted to see me be more active with the infection control in those doctor's offices.
• She went places in this hospital that I had never been and found stained ceiling tiles that needed to be replaced.

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Received January 2002

• During the rounds, there was a heavy focus on equipment used in the clinical and visitor environment-- tears in stretcher mattresses, tears in chairs in waiting rooms, cafeteria trays with cracks.
• One surveyor focused on the dating of juices in the refrigerator. He wanted each individual juice to be labeled with the date it was placed in the refrigerator. We researched sanitation rules (nothing requires this) and he was satisfied with a policy of rotating stock (Last in, first out).
• During the infection control interview, Employee Health was asked about pre-employment evaluations, how Agency staff Employee Health was evaluated, skin-testing protocols, and "How do staff know when they should not come to work?" She described an individual pushing a laundry cart who had a rash and was later identified to have measles--numerous exposures. (Employee Health provides a handout addressing this during the pre-employment evaluation.)
• The infectious diseases physician was asked about any "exotic pathogens" being seen at the facility.
• The infection control professional was asked about "Interesting Opportunities" she had had-- noting that we find lots of unusual things interesting.
• The surveyor was very thorough; she referenced specific items in the minutes she wanted to follow-up.

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Received December 2001

Skilled Facility Infection Control Survey - nurse surveyor

• Surveyor did not like the fact that pillows were uncovered in the clean utility room, even though the room was closed off. She felt that the pillows should be covered at all times.

Long-Term Care Infection Control Survey

• Surveyor found one linen cart with an open bottom.

Physician Offices Infection Control Survey

• Nothing really touched upon here in area of infection control.

Home Health Infection Control Survey

• No comments here. The surveyor did go on a site visit and observe the nurse.

Acute Facility Survey

• Temperature chart on automated medication machine---surveyor looked at temperature log for the past year and found a couple of days where the temperature was higher than she felt it should be. Her point was that there needed to be documentation of actions taken to address this.
• Asked about employee flu shot program (participation).
• Asked about employee infection trends/outbreaks.
• Asked about sharps program---many questions here, wanted to know about frontline staff involvement, physician involvement, operating room staff involvement (basically quizzing infection control professional [ICP] on knowledge of standard).
• Asked MANY questions about ICP involvement in construction---did ICP review building plans, did ICP do continual monitoring of work, could ICP stop construction work if necessary, who did ICP work with in this area, were patient traffic routes (during construction) evaluated, etc. (This was probably on her mind since we are in the middle of completing a parking deck, building a new emergency room, and abating asbestos in one wing of the facility).
• Asked MANY questions about monitoring of air quality and water quality---who did it, how often, where was it reported, what was being done in this area during construction, did we have backup plans for disruption of services, etc.
• Asked about general infection control program (surveyor reviewed minutes). Surveyor said infection control program was very organized.
• Surveyor reviewed ICP education/evaluation (personnel) file.
• Asked about TB risk/trends in county.
• Asked about bioterrorism preparedness in facility---what was in place, what was being done, training in area, were we working with county agencies, etc.

Other Issues Addressed---nothing really new here:

There was heavy emphasis on environment of care components. Much grilling here---who is involved, where is reporting done, how often is reporting done, how is each of the 7 components addressed, use of "task force" versus "subcommittee", etc.

• Medication use/storage/disposal.
• Follow-up of any adverse drug reactions.
• Patient safety program---organizational approval of program, mechanism for conducting proactive risk reduction programs, staff support, etc.
• Medical staff bylaws (board certification of department directors).
• Credentialing of staff (physicians, contract staff)---up-to-date MD privilege list kept in patient care areas.
• Patient confidentiality (use of assignment boards on units).
• Availability of dietitians over the weekend (did we evaluate need for this).
• Pain assessment.
• Discharge instructions matching between nursing/dietitians/physicians.
• Availability of transcription over weekend (for getting those histories and physicals on the chart in time!).
• Space/staffing issues.
• Life safety: inspection of fire extinguishers monthly, access (door blocking) in utility rooms, storage closets with smoke detectors/sprinklers, closing of fire doors, etc.

The surveyor(s) did come back to the hospital during an off (evening) shift. Pediatrics was visited during this visit. They were evaluated as to how long it took for a nurse to come to the desk (if no one was there when the surveyor walked up) and whether or not the medication room was locked when a nurse was not present. We have rooming-in with our newborns and special family way/pediatrics identification badges, so infant safety was not an issue.

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Received October 2001

• The main suggestion I have for Infection Control is that Infection Control personnel need to be involved in the opening conference and the Performance Improvement (PI) Overview. We included some infection data in the PI Overview and I was there as well. They saw from the beginning that Infection Control is important in the institution, that we are part of the PI process, and that we have surveillance and statistics in place.
• They were very impressed with was my annual report. I had put together a very extensive annual report for 2000 with all of the data, statistics, studies, projects, and goals in one place that was easy for the surveyor to review.
• In the Infection Control Interview, they asked a few questions about projects we had worked on.
• They asked about Employee Health and needlesticks and what we had done to prevent and decrease injuries.
• They asked about the sentinel event alerts and the one on CJD had just come out and we were able to tell them what we are doing with our policies on that. Throughout the survey they asked a lot of questions about patient safety so I mentioned in the Infection Control interview before they could ask that we were involved in the patient safety initiatives and that infection control is a vital part of patient safety.
• I really think that the interview is just a validation session of what they have seen while in the institution. I think that the up-front presence of infection control, our presence at the unit visits, seeing the involvement of Infection Control in the institution was what they were looking for. Our interview turned out to be more of a chat session.
• Our Infectious Disease Consultant was present and the surveyor was impressed with her, and they discussed several issues unrelated to the survey.
• We did not receive any recommendations related to Infection Control.

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Received October 2001
Our hospital was surveyed February - March 2001.

• The surveyor asked me to describe our Infection Control Program. I provided her with a copy of the Infection Control Program Annual Report and discussed this with her.
• She reviewed the most current Infection Control Committee Meeting Minutes (draft) and asked questions related to the items listed.
• She asked if I was involved in Construction & Renovation projects and describe my involvement in these areas.
• During the Building Tour she opened every closet, checked soiled and clean utility rooms, looked overhead for fire penetrations, she looked for storage of items on the floor. After surveying 4 floors, she found where someone had unboxed some new items, and they had placed the box on the floor due to the trash pick up schedule in that particular area. She did not write up this finding.
• This surveyor was extremely thorough; however, she was not intimidating. In fact she complimented our program, and referenced the storyboards which we had displayed in the conference room.

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Received September 2001
Employee Health questions:

• Do you have a vaccine program in place? What vaccines do you offer and to whom?
• What is your annual compliance with your TB screening program?
• What is your policy in regard to handling infectious/communicable diseases/conditions among employees?

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Send information to
spice@unc.edu

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The Statewide Program for Infection Control and Epidemiology (SPICE) at the University of North Carolina at Chapel Hill is funded by the General Assembly of North Carolina to serve the State. SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.

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University of North Carolina (UNC) at Chapel Hill disclaimer

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Last modified: September 2, 2009