Infection Control is Front and Center at Annual Joint Commission Session

By A.J. Plunkett

Step up leadership oversight of water management at your facility. Make sure your infection preventionist (IP) is involved in all parts of construction and renovation projects. Beware of mold infections in both people and buildings. And get over offending people—controlling the next pandemic is a priority.

Those were just some of the hospital safety issues reviewed during this year’s Executive Briefings session by The Joint Commission at its headquarters outside of Chicago.

Infection control dominated the day’s presentations, which also looked at expectations for sterile compounding, Legionella control, using personal protective equipment, medication management, lowering maternal death rates, and, of course, ligature risk and suicide prevention.

Suicide prevention remains a key concern among TJC surveyors, but compliance officers should know the Life Safety Code® will always trump any ligature risk, said Herman A. McKenzie, MBA, CHSP, who was named as the new director of the Department of Engineering under the Standards Interpretation Group in early September.

However, ligature risks and infection control continue to top hospital citations for immediate threat to life and safety, highlighting the continuing theme for the Executive Briefings—that the environment of care and clinical outcomes are intrinsically linked.

Sylvia Garcia-Houchins, MBA, RN, CIC, emphasized the need for multidisciplinary teams, whether overseeing water management, mold control, instrument sterilization, or preparedness for the next infectious epidemic that is sure to come.

While Ebola and measles may be the latest infectious diseases to get attention, influenza remains the pandemic that everyone should fear, said Garcia-Houchins. The flu has the potential to kill millions. “Are you ready to be the center of that?” she asked.

Here are the highlights from the presentations by Garcia-Houchins. Future issues of Inside Accreditation and Quality will cover each of these subjects and other Executive Briefings presentations in more depth.

Water management

Legionella is already in your facility, no matter what your latest tests might show, warned Garcia-Houchins. It exists in water systems everywhere, but you must know how to prevent it from growing—or how to keep it from becoming a patient safety hazard if it does grow, she said.

She pointed to survey-and-certification letter S&C 17-30 from CMS on Legionella management, as well as the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Guideline 12, Minimizing the Risk of Legionellosis Associated With Building Water Systems, and ANSI/ASHRAE Standard 188-2018, Legionellosis: Risk Management for Building Water Systems as the top guidelines to use.

If you are a smaller facility and cannot afford to get those standards straight from the source, the CDC has provided a free, online toolkit based on those standards that provides a step-by-step approach to water management.

Surveyors will want to see that you are not only assessing your risk for Legionella but also have a mitigation strategy to actively manage it, Garcia-Houchins said. “We’re good at doing the risk assessment. We’re not good at taking the next step.”

Be particularly concerned about water that remains dormant in pipes, including during renovations and new construction, especially if you are trying to become Leadership in Energy and Environmental Design (LEED) certified. Certification is great, but a system that meets LEED standards could be slower to cycle water, potentially leading to Legionella growth. Discuss the risks and mitigation strategies with your water management team and any contractors you hire for that purpose.

That team must be multidisciplinary and include facilities managers, your hospital risk manager, nurses, and IP specialists, Garcia-Houchins said. You cannot depend just on a water management contractor. No one knows your buildings better than your people, she emphasized.

Know too that surveyors expect your water management plan and team to concentrate on more than just Legionella. There are many infectious diseases that start with water.

Tip: The route to a successful survey is to follow the same path as TJC in determining expectations, said Garcia-Houchins, repeatedly.

Start with the rules and regulations that govern the issue, including any local authorities having jurisdiction.

Then determine the expectations set out in Medicare’s Conditions of Participation (CoP) or Conditions for Coverage (CfC). Check for any manufacturer’s instructions for use (MFU). If you still are uncertain about expectations, go to evidence-based guidelines and national standards on the issue. Need more direction? Find out if there are any consensus documents on the subject.

Finally, what’s in your own policy? Organizations are often cited not for a failure in procedure or policy, but for not following their own established policies, said Garcia-Houchins and others during the Executive Briefings. (For more on TJC’s approach to requirements, see pp. 15–18 of the Commission’s April Perspectives magazine.)

These three steps form the approach you should use, she said. “If you do, you will get to the standard for your area,” but remember that every state or locality can be different.


Mold is another water-related infectious problem that is getting more attention but has always been a concern, said Garcia-Houchins. Just as Legionella is always present in your pipes, mold spores are always drifting through the air. It’s in that dust that’s everywhere, she said. “We’re all breathing in mold right now. Every one of us. Every day.”

For mold to grow, it needs a nutrient (dust or dirt), moisture, and the right temperature.

Beware of anything that creates dust, which includes:

  • Drilling through walls or ceilings
  • Removing carpets or tiles
  • Removing ceiling tiles
  • Air movement over the tops of ceiling tiles
  • Anything that stays wet for more than 72 hours
  • Disruptions of air supply or changes in air pressurization
  • Improper filters
  • Open windows or doors
  • Vacuum cleaners
  • Fresh plants or flowers

It is important to watch for reports of respiratory problems in patients or staff. If someone complains, for instance, of a stuffy nose, wheezing, or itchy eyes that only occurs while at work, that could be a key indicator of a mold problem, she warned.

If someone spots a stained or moldy ceiling tile, don’t just replace it—search for what caused the stain. Even if the spot with the mold dries out, the mold spores will travel until they find moisture. “As it dries out, it wants to find a new home,” she said.

If your C-suite is balking at the extra expense to keep looking for mold and to protect against it, provide them this information: According to a 2006 Journal of Hospital Infection article, all outbreaks of nosocomial aspergillosis are because of airborne sources; they carry a 57.6% fatality rate in high-risk patients and a 39.4% fatality rate in patients without severe immunodeficiency.

Leadership has to take responsibility for management of infection control, said Garcia-Houchins, and it can be scored under Leadership standards.

“You will save money if you plan for water and mold, if you do it early and you include the right people,” she advised.

Construction and infection control

Your IPs should be part of the planning of any renovation, construction, or even repairs within your facility to help mitigate problems.

They should be familiar with at least the 2014 FGI Guidelines for Design and Construction of Hospitals and Outpatient Facilities, the recognized guide under EC.02.06.05, which requires hospitals to manage risks associated with construction, demolition, and renovations.

The CDC also has its 2003 Guidelines for Environment Infection Control in Health-Care Facilities, noted Garcia-Houchins.

Remember that your ventilation system is owned by the contractors until they turn over the new building, and if they start up that system to provide heat or cooling to their crew before the air filtering is set up, that can create a host of dust and infection control problems, Garcia-Houchins warned.

The IPs must be involved, but they must also be competent, she said. Have they been involved in a construction project or building renovation? Do they have the right experience? Do they have time to tackle this project?

You are expected to perform an infection control risk assessment (ICRA) with every project. It should start with the blueprint, she said. However, the IP shouldn’t be the only person conducting the assessment—a multidisciplinary team that includes not only facilities but also nursing and other project stakeholders should sign off on the ICRA.

Engage staff. Anyone who goes by the construction site and sees dust or anything else that could pose a problem should be tasked with reporting it. “Yeah, it’s dusty every morning, but they don’t know to call somebody,” she said.

For leadership (the money people), Garcia-Houchins recommends considering contractual penalties for failures to follow the infection control plan.

In addition, enlist and listen to your environmental services crews: If someone is complaining, “I keep cleaning this and it’s always dusty 10 minutes later,” that could signal a problem.

Personal protective equipment (PPE)

Surveyors will want to know your policies on PPE. But it’s not just a matter of satisfying the surveyors, said Garcia-Houchins. “You have a responsibility to your staff.”

Not only do you need to provide training and education on when and what kind of PPE to use, but you need to provide the correct PPE at all times.

She told the story of her son, who is also a nurse and needs to have extra-large gloves, but every day after showing up for work he would have to call down to supply to have the correct size gloves sent to his unit.

No staff member should have to wait for the correct PPE or go looking for it in an emergency. It’s up to the hospital to protect its staff, she said. “We’re not talking about survey, we’re talking about safety. Please remember that.”

The next pandemic

PPE has proven to be a vulnerable spot in every facility’s planning for emergencies or infectious disease outbreaks.

Planning doesn’t just involve dealing with the arrival of flu season or an outbreak of measles. It’s preparing your facility and your staff to deal with the unknown, she said.

Think about your whole organization. Consider making it a health policy for employees to stay home if they are sick.

Go to where your patients enter the facility and note what you see, Garcia-Houchins said. Do you see the sign telling patients to cover their coughs? “This is your early warning system.”

Telling staff, patients, and vendors early and often to take precautions is essential. Be proactive about asking someone with a cough or other symptoms to wear a mask, she said. “Get over offending people.”

Your facility should have clearly visible signs with descriptions of possible symptoms posted throughout the hospital, especially at entrances and waiting rooms. That includes entrances for staff, she said.

Signs with illustrations of symptoms or problems help to educate staff just as well as patients. And posters will get their attention; emails on the subject may never get read, she said.