Hospital operations are usually subject to regulatory measures by various accreditation agencies. The Joint Commission on Accreditation of Health Organization (JCAHO) is one such organization. JCAHO, currently the Joint Commission, traces its existence back to 1976. It focuses on the promotion of hospital reform initiatives to help facilitate patient-centered outcomes. The commission is a private nonprofit organization with a mission to offer continuously health care services in collaboration with other organizations through the evaluation and inspiration of health care organizations into excellence. It achieves this mandate by annually accrediting health care institutions according to Medicare reimbursement requirements (TJC, 2013).
The JTC requires that organizations meet specific components of control and infection prevention programs in the US. These components include having a comprehensive surveillance system. This requirement is part of the 2011 National Patient Safety Goal (NPSG) 07.05.01’s effort to reduce surgical site infections (SSIs). The NPSG requires the organizational existence of the following practices. First, that there exist frequent risk assessments for SSIs at a facility-related predetermined timeframe. Second, accredited organizations should select SSI preventive measures using EBP guidelines. Third, the TJC leadership should monitor organizational adherence to the best EBP guidelines. Finally, the TJC should assess the effectiveness of individual hospital SSI prevention practices (TJC, 2013).
The Joint Commission recognizes hospital-associated infections (HAIs) as a dire medical issue. Based on the TJC (2013), about 500,000 HAIs happen on an annual basis with significant costs and mortality as well as morbidity for hospitals and patients, in that order. Given such statistics, the commission prioritized HAIs and, in 2010, began publishing NPSGs that focused on their prevention and mitigation. The NPSGs touched on four kinds of HAIs, namely multi-drug resistant organisms (MDRO), surgical site infections (SSIs), catheter-associated UTIs, and central line-associated bloodstream infections (TJC, 2013).
The goals specify the EBP requirements necessary in the prevention and mitigation of HAIs. They offer the direction required for accredited hospitals to implement effectively prevention mechanisms. The hospitals, on their part, require additional assistance from the JTC to attain success in the implementation of NPSGs and the standards. The commission’s SSI Change project looks at identifying, confirming, and providing accredited hospitals with directions that aid in the implementation process (Kaminski, et al., 2012).
In summary, the Joint Commission understands that there is a need to prevent the incidence of HAIs and associated clinical and economic burden. Ideally, the Commission collects information on the following practices. First, it identifies effective practices that help in implementing the NPSG. Second, they monitor the types of surveillance methodologies that hospitals employ for enhanced patient care. Third, the limitations associated with patient education. Fourth, the methods through which nurses and physicians receive education on NPSG 07.05.01. Fifth, the approaches hospitals and other organizations use in the implementation of NPSG objectives. Finally, the resources used and additional costs incurred during program implementation. These moves, directly and indirectly, help reduce the length of stay/excuse days.
References
Kaminski, G., Britto, M., Schoettker, P., Farber, S., Muething, S., & Kotagal, U. R. (2012). Developing capable quality improvement leaders. BMJ Quality and Safety, 21 (11), 903-11.
Perl, T., & Sydnor, E. (2011). Hospital Epidemiology and Infection Control in Acute-Care Settings. Clinical Microbiology Reviews, 24 (1), 141–173. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021207/
TJC. (2013). The Joint Commission’s Implementation Guide for NPSG.07.05.01 on Surgical Site Infections: The SSI Change Project. Oakbrook Terrace, IL: The Joint Commission.
