The Joint Commission Just Drew a Line in the Sand on Hand Hygiene

By Clean Hands - Safe Hands

The Joint Commission Perspectives newsletter just announced a major overhaul to their hand hygiene standards. If you haven’t seen it, you need to read it now. The Joint Commission frequently gets a bad rap, but they got this one right, and in doing so they have taken the boldest stance yet when it comes to hand hygiene. Come January, it is no longer enough to simply monitor hand hygiene or have a system to try to improve it; your hospital staff has to actually perform hand hygiene every single time.

Starting in a few weeks, if a Joint Commission official sees any individual provider fail to clean their hands one time, your hospital will be cited and you will have to show improvement to maintain accreditation. With this new standard, they are appropriately considering a single missed hand hygiene opportunity a threat to patient life.

The update reads: “Effective January 1, 2018, for all accreditation programs, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under Infection Prevention and Control (IC) Standard IC.02.01.01, EP2: ‘The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.’”

This is a dramatic change over the previous Joint Commission standard, which was to “implement a hand hygiene program, set goals for improving compliance with the program, monitor the success of those plans, and steadily improve the results through appropriate actions.” These program standards have not changed since they were established in 2004, and apparently The Joint Commission has determined that 14 years is more than enough time to put these programs in place. Now it’s time to raise the bar.

The sad reality is that nearly all hospitals are relying on fatally flawed Direct Observation methods, so this is going to be a big wake up call for them. At one point, this was the only way to improve hand hygiene, but today it is the Fool’s Gold Standard, and it can dangerously lull organizations into a false sense of security. One of our hospital partners recently went through a survey by The Joint Commission. The surveyor said that electronic hand hygiene monitoring is the “Gold Standard,” and the hospital received a special accommodation for their commitment to hand hygiene.

While electronic hand hygiene systems can provide hospitals with varying levels of this new Gold Standard, most don’t support real behavior change. In order to live up to the new standards, organizations need to go beyond just monitoring the problem…it takes a real and sustainable change. I recently met with the Chief Quality Officer of a major health system and he summarized it best: “You can’t make a chicken fatter by weighing it.”

The only effective method to lead to sustainable behavior change with hand hygiene is to leverage a clinician-centered, electronic hand hygiene performance system that combines in-the-moment feedback with a process of continual, positive behavior change.

If you would like to learn more about how we create a process of continual, positive behavior change, please feel free to download our white paper.

Here’s The Joint Commission’s announcement.


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