Infection Control Standards Cited Frequently by Joint Commission in Ambulatory Care and Office-Based Surgery Settings

By on 6:32 AM

The Joint Commission has identified standards cited most frequently as "not compliant" during 2015 surveys of accredited ambulatory health care (AHC) and office-based surgery (OBS) organizations, and several come from the Infection Prevention and Control (IC) chapter.

IC.02.02.01 (the organization reduces the risk of infections associated with medical equipment, devices, and supplies) was the second most-cited standard for AHC organizations and tied as most-cited standard for OBS practices. Nearly half of all AHC organizations received requirements for improvement (RFIs) for this standard, while half of OBS practices received RFIs.

As Mike Dye, senior associate director of the ambulatory care program, notes in an Ambulatory Buzz post, this standard has made the top-cited standards list for three consecutive years. He said, "This IC standard gets cited more often than not and represents many immediate-threat-to-life situations that occur during survey."

New to the Joint Commission's most-cited standards list is IC.01.03.01 (the practice identifies risks for acquiring and transmitting infections). It is the seventh most-cited standard for AHC organizations (26% RFIs) and fourth for OBS practices (24% RFIs).

Also on the OBS most-cited list, coming in tied for eighth, is IC.02.04.01 (the practice offers vaccination against influenza to licensed independent practitioners and staff), with 17% RFIs. It is tied with National Patient Safety Goal.07.01.01 (Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines).

Need help maintaining compliance with regulations and standards, including The Joint Commission, the Centers for Medicare & Medicaid Services (CMS) AAAHC and more? Contact Infection Control Consulting Services (ICCS). ICCS provides a wide range of services, including assistance with accreditation survey preparation, development of a corrective plan of action related to survey deficiencies, development of a infection prevention risk assessment and much more.


Phenelle Segal, RN, CIC, FAPIC

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services LLC (ICCS). Phenelle has more than 30 years' experience providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. Her services focus on assisting hospitals, ambulatory surgery centers, dental office and oral surgery practices, doctor's offices, nursing homes and other organizations with implementing and maintaining an infection control program that: complies with The Joint Commission, AAAHC, Centers for Medicaid and Medicare Services (CMS) and other regulatory agencies; respond to situations of noncompliance; and improve the processes for reducing risk.