infection prevention
By Sylvia Garcia Houchins , MBA , RN , CIC
Preparation for Survey : Tips for Infection Preventionists
It is difficult for an infection preventionist ( IP ) to anticipate what to expect during a healthcare organization ’ s survey . With more than 30 years of experience as an IP , I have personally participated in 10 full , unannounced Joint Commission surveys , a few for-cause Joint Commission surveys , three intense occupational health and safety visits , and several state surveys . So , how does one become “ good at survey ” when the opportunities may be few and far between ?
During the first few surveys , I was
IPs should volunteer to participate in mock surveys – even if they are not infection controlrelated .
The experience will help provide information on how an organization functions during survey , its processes that are in place , who is who on its team , as well as the survey process itself .
• allowed to accompany the physician , nurse , administrator , and life safety surveyor . All were terrific teachers , and I learned a lot from each . The experience also prepared me to act as a “ guide ” for surveyors during subsequent surveys and provided me the confidence to explain to surveyors why I did not think my organization was out of compliance with the Joint Commission standards or Centers for Medicare and Medicaid Services ’ ( CMS ) Conditions of Participation ( CoP ).
IPs should be proactive in asking to be allowed to participate in surveys and should not wait to be asked . Instead , IPs should volunteer to participate in mock surveys – even if they are not infection control- related . The experience will help provide information on how an organization functions during survey , its processes that are in place , who is who on its team , as well as the survey process itself .
IPs should use a systematic approach to determining compliance with regulatory requirements . For example , before working at the Joint Commission , and while working as a consultant , I helped many organizations prepare for their surveys and respond to adverse survey results including immediate jeopardy . I always followed a hierarchical approach to compliance . First , I determined if there was a law or regulation that applied , followed by ensuring compliance with CMS CoPs that included researching and interpreting instructions for use and seeking clarity from manufacturers . Then , if needed , I always turned to locating supporting literature , evidence-based guidelines , and best practices to help .
In April 2019 , this approach was published in the Joint Commission ’ s publications , Perspectives , to help organizations learn how become compliant with Joint Commission infection prevention and control standards and to provide a good starting point for preparing for a survey .
But , merely following the approach is not enough . Most IPs are incredibly dedicated and resourceful , but I find that many overthink or underthink what is required for survey . Below are some “ tips ” that will help an IP prepare for survey .
➊ Make sure your organization can provide evidence that the IP is qualified and competent . There is an important distinction between qualified and competent and we often find that organizational leadership does not understand the difference . The following information provides clarity on the differences as well as an example of what could be identified as an issue during survey .
Qualifications : Healthcare organizations must define an IP ’ s qualifications based on his or her specific-to-job responsibilities . Qualifications for infection control may be met through ongoing education , training , experience and / or certification . For example , organizations may define an IP ’ s qualifications as “ ongoing experience practicing in the infection prevention and control field as well as initial and ongoing infection prevention-specific education and training .” Or , they may require that , “ The IP has three years of experience in a surgical setting and certification in infection prevention and control or able to obtain certification within two years of hire .”
Competency : This ( see Joint Commission standard HR . 01.06.01 ) differs from education and training in that competency incorporates knowledge , technical skills , and ability . All are required to deliver safe care correctly and perform technical tasks . Assessing competency , then , is the process by which the organization validates , via a defined process , that an individual has the ability to perform a task consistent with the education and training provided . An example of a competency assessment could be the validation that an IP can perform surveillance correctly by providing cases studies and determining that the IP correctly identifies whether the case meets the definition of a healthcare-associated infection . Competency may also include confirming that he or she correctly identifies the type of infection , correctly calculates infection rates , and presents results in a clear manner with relevant interpretation .
A common mistake that is scored during survey happens when an IP who is not competent themselves , signs off on the competency of a person who is performing a task , for example high-level disinfection or sterilization . The IP may be knowledgeable or have training related to disinfection and sterilization , but he or she is not competent to perform the tasks and identify and problem solve when issues arise . In the example , of sterilization , the IP knows the basic steps for reprocessing instruments but could not assess that each step is being done correctly or how to identify