Unraveling the Mystery of The Joint Commission Survey: What is the Expectation Around Hand Hygiene?
Hand hygiene in healthcare settings is complex and building a high-quality hand hygiene program isn’t easy. Since 2004, The Joint Commission (TJC) has expected hospitals to address hand hygiene as outlined in National Patient Safety Goal 07.01.01 which requires healthcare organizations to implement a hand hygiene program, set goals for improving compliance, monitor the success of those plans, and steadily improve. While many hospitals have actionable goals and have improved over time, others have stagnated. In 2018, TJC issued an update stating that “any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency.” This update has caused confusion and uncertainty among IPs and hospital leadership.
During this interactive breakfast symposium, you will hear directly from Sylvia Garcia-Houchins, Director of Infection Prevention and Control at TJC. Sylvia will detail TJC’s expectations for hospital hand hygiene programs, the science that supports the standards, and most importantly the risk to patients and staff when standards are not met. A successful survey should be the mark of an organization committed to quality and safety, and Sylvia will provide valuable tips that will help your hospital on its hand hygiene journey.
At the end of this symposium, you will be able to:
- Review TJC standards and the supporting evidence.
- Discuss why a valid hand hygiene compliance rate should be the starting point of a hand hygiene journey and how it can be obtained.
- Describe the components of a successful hand hygiene program through TJC’s eyes.
- Examine your own hand hygiene program and assess the necessary next steps needed to improve quality and safety in your hospital.