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CE Article: Unannounced surveys raising the bar for facilities; Hand hygiene highlights valuable lessons for hospital

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Learning objectives: After reading this article, you will be able to

  1. Interpret The Joint Commission's standards for hand-hygiene compliance
  2. Discuss how The Joint Commission's unannounced survey and tracer methodology might affect infection control (IC) compliance

Massachusetts General Hospital (MGH) in Boston uses spies to monitor hand-hygiene compliance. The hospital has focused on internal processes and worked to change its culture to support solid hand-hygiene practices.
In short, "We have a hand-hygiene program that is just about as good as most any that I've seen," says Gregg Meyer, MD, senior vice president for Quality and Patient Safety at MGH.

Even so, when The Joint Commission (formerly known as JCAHO) showed up in December 2006 for an unannounced survey, the hospital was hit with a recommendation for improvement (RFI) when staff members failed to comply with established hand-hygiene practices.

Despite positive comments from surveyors about some of their hand-hygiene observations, several staff members were observed failing to wash their hands or use an alcohol-based hand sanitizer both before and after patient contact, says Meyer.

The breaches occurred in situations in which staff members working with patients stopped to adjust a piece of equipment and then went back to the patients without washing their hands or using an alcohol-based hand sanitizer, he says.

The Joint Commission's surveyors issue an RFI related to hand hygiene if they observe three or more instances of noncompliance, which Meyer calls, "a very high but appropriate bar."

The Joint Commission standards measure hand-hygiene compliance as part of the Elements of Performance for IC.4.10, and also under National Patient Safety Goal 7. Specifically, The Joint Commission will be looking for healthcare providers to comply with standards set forth by the Center for Disease Control and Prevention. Click here for a list of frequently asked questions about Goal 7.

Although MGH was fully accredited, surveyors issued 10 RFIs during their visit. In the wake of the survey, Peter Slavin, the hospital's president, issued a memo to staff members outlining the deficiencies and asking them to take immediate steps to address them.

It has also taken steps to address the deficiencies found. Although its monitoring program for hand hygiene will remain the same, the awareness of this issue has gone up exponentially, he says. For more about the importance of clean hands, click here.

The survey process

This was MGH's first survey since The Joint Commission changed its inspection format from announced to unannounced surveys using the new tracer methodology.

Surveyors use the tracer methodology by selecting a patient, resident, or client, and following that individual's record as a road map to track and evaluate the organization's compliance with various standards.

Under the former survey process, healthcare facilities had advance notice that a survey team would be visiting. As a result, organizations would often ramp up compliance efforts before the survey, making sure the facility and staff were prepared when surveyors arrived.

Not so under the new model. "Surveyors spend a lot more time in patient-care areas and a lot less time sitting in a board room listening to presentations," says Meyer. To learn about preparing for a hospital survey, click here.

Since the changes in the inspection system, the average number of deficiencies per hospital has jumped from three to seven, and the percentage of hospitals with conditional accreditation has risen from 1% to 2.8%, according to The Boston Globe. Hospitals with more than 13 RFIs are given conditional accreditation.

"While data has shown some increase in the volume of issues uncovered since converting to unannounced surveys, the survey should not be the motivation behind increasing compliance with the standards," says Elizabeth Zhani, a media relations specialist with The Joint Commission. "The goal of unannounced surveys is for organizations to comply with the Joint Commission's standards on a continual basis, not just at the time of survey. Therefore an organization should not rely on an unannounced survey to determine if their employees are washing their hands."

Higher standards all around

For its part, The Joint Commission says the goal is not to make the survey more difficult but to increase compliance.

"The survey should not be seen as a tool for keeping organizations in compliance with Joint Commission standards," says Zhani. "The unannounced survey is a way for organizations to validate their efforts to identify compliance issues through the periodic performance review [PPR], and to check their success in addressing those issues."

The PPR is a compliance assessment tool designed to help organizations with their continuous monitoring of performance and performance improvement activities on an annual basis, according to The Joint Commission.

The organization evaluates itself using the PPR and comes up with a plan of action to focus on areas that need improvement.

In the wake of its survey, MGH is taking another look at its processes.
Although its monitoring program for hand hygiene will remain the same, the awareness of this issue has gone up exponentially, says Meyer.

Lessons learned

In his memo to staff Slavin wrote, "On the heels of [The Joint Commission] visit, we sent out a message to staff, reminding everyone of the steps we all must take not simply to respond to [The Joint Commission] team's comments, but to do the right thing for our patients."

Source: Briefings on Infection Control, June 2007, HCPro, Inc.

1. "FAQs for The Joint Commission's 2007 National Patient Safety Goals" at
2. "Hand Hygiene Resource Center: Frequently Asked Questions at
3. "Preparing for a Hospital Survey" at

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