ANALYSIS AND NEXT STEPS
The Joint Commission: New and Revised Requirements for the Infection Prevention and Control (IC) Chapter

What’s revised and new in the Joint Commission IC standard?

The updates are driven by a standardized approach that simplifies the requirements and eliminates those not providing value to healthcare facilities. The revised standards support quality and safety and align with the requirements from the Centers for Medicare & Medicaid Services (CMS), Conditions of Participation (CoPs), and the Centers for Disease Control and Prevention (CDC).

The Joint Commission also introduced a new standard, IC.07.01.01, with two new elements of performance (EPs) to support health care facilities in preparedness for high-consequence infectious diseases or special pathogens. The new Standard requirements were driven by the recent history of outbreaks, including Ebola outbreaks, and the COVID-19 pandemic, that caused health care disruption on a global scale.

Below is the simplified version of the IC standard explanation; however, the accredited Joint Commission hospitals and critical access hospitals will receive access to the new Infection Control Program Assessment Tool, which will provide details about the specific requirements.

New requirements within the IC chapter:

Governing body and leaders’ responsibilities: 04.01.01 – EP1 and 05.01.01 – EP1 and EP2
Policies and procedures: 04.01.01. – EP3, EP4
Policies and procedures for processing reusables: 04.01.010 - EP4
Access to and use of public health and safety data: 05.01.01 – EP1 and 06.01.01 – EP1
Protocols for HCID or special pathogens: 07.01.01 – EP1 and EP2

Eliminated EPs within IC chapter*:

Infection prevention and control plan
Elimination of IP plan
*The requirements for both topics are now required under the new or existing EPs.

Existing requirements moved to new EP location within the IC chapter:

Program leader responsibilities: 04.01.01 – EP1 and EP2
Program resources: 05.01.01 – EP1
Risk identification and annual review: 06.01.01 – EP1 and EP2
Setting prioritization goals: 06.01.01 – EP1
Use of evidence-based national guidelines: 04.01.01 – EP3
Surveillance of IP processes: 06.01.01 – EP 3
Outbreak management: 06.01.01 – EP4
Hospital-wide IP program: 04.01.01 – EP5
Implementation: 06.01.01 – EP3
Communication of responsibilities: 06.01.01 – EP4
Communication to staff: 05.01.01 – EP2, 06.01.01 – EP4 and 07.01.01 – EP1
Reporting: 04.01.01 – EP3 and 07.01.01 – Ep1
Patient notification: 04.01.01 – EP4
Occupational health: 06.01.01 – EP5
Staff vaccination: 04.01.01 – EP3 and 06.01.01 – EP5
Practices to prevent HAIs: 04.01.01 – EP3 and 06.01.01 – EP 3
Communication of results: 05.01.01 – EP2

Requirements moved outside of the IC chapter:

Influx of infectious patients: EM requirements
Storage and disposal: EC 02.02.01

Reference: TJC Reference Guide: Infection Control Standards

NEW REQUIREMENTS DETAILS:

Governing body and leaders’ responsibilities.

Document and track the following:
Implementation | performance | sustainability | resources | showing that problems are addressed.

Policies and procedures.

Written documentation of the following:
Activities | methods | control transmission
Separate policy to address cleaning, disinfection, and sterilization of reusable medical and surgical devices and equipment.
All documentation must include relevant law regulations, guidelines, and expert opinions.

Access to and use of public health data.

Show data displaying the risk to patients and staff, including the following:
Community and population served | provided services | analysis of surveillance activities | relevant IC issues.
How do the services we provide/activities performed by EVS reduce HAIs? How is it reducing patients' exposure? Work with IP professionals within your facility to obtain and use the data.

Highly Contagious and Infectious Diseases (HCID) or special pathogens protocols.

Develop and implement the protocols that are readily available (in partnership with the infection control committee)
Examples include:
Procedures for screening and isolation | procedures to inform (public health authorities/ key staff) | procedures to support continued and safe care.
Participate in developing the protocols that fit your facility; train and communicate with staff.

NEXT STEPS:

Improve policy and procedures.
Prepare for HCIDs and special pathogens.
Improve cleaning, disinfection, and sterilization process.
Become part of the multi-disciplinary team to ensure contribution to public health data alongside infection preventionists.