JCAHO IC.4.10 and NPSF Goal 7

JCAHO IC.4.10:

Elements of Performance;

1. Interventions are designed to incorporate relevant guidelines for infection prevention and control activities.

       Interventions are implemented which include the following  (EPs 2and 3):

2. A hospitalwide hand hygiene that complies with current CDC and Prevention (CDC) hand hygiene guidelines(National Patient Safety Goal 7, requirement 7a).

3. Methods to reduce the risks associated with procedures, medical equipment and medical devices, including the following:

       Appropriate storage, cleaning, disinfection, sterilization, and/or disposal of supplies and equipment

       Reuse of equipment designated by the manufacturer as dispoasl in a manner that is consistent with regulatory and professional standards

       The appropriate use of personal protective equipment

4. Implementation of applicable precautions, as appropriate, is based on the following:

       The potential for transmission

       The mechanism of transmission

       The care, treatment, and service setting

       The emergence and reemergence of pathogens in the community that could affect the hospital

5. Screening for exposure and/or immunity to infectious diseases  that licensed independent practitioners, staff, student/trainees, and volunteers who may come in to contact within their work is available as warranted

6. Referral for assessment, potential testing, immunization and/or prophylaxis/treatment, and counseling as appropriate of lcensed independent practitioners, staff, students/trainees, and volunteers who are identified as potentially having an infectiousdisease or risk of infectious disease that may put the population they serve at risk

7. Referral for assessment, potential testing, immunization and/or prophylaxis/treatment, and counseling as appropriate of patients, students/trainees, and volunteers who have been exposed to infectious disease(s) at the hospital and licensed indepent pratitioners or staff who are occupationally exposed

8. Reduction of risks associated with animals brought into the hospital (such as, management of animal waste). 

   National Patient Safety Goal 7:

   Reduce the risk of health care-associated infections.

   Requirement 7A: Comply with current CDC hand hygiene guidelines. Note: This requirement is scored at standard at IC.4.10 EP 2.

   Requirement 7B: Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with health care-associated infections.