Infection Prevention

Citation

TJC HR.11.02.01

The hospital defines and verifies staff qualifications.

The standard addresses defining staff qualifications by job responsibility, including references to infection control, laboratory, rehabilitation, interpreter, and respiratory care qualifications.

Citation

TJC IC.04.01.01

The hospital has a hospitalwide infection prevention and control program for the surveillance...

The hospital must maintain a comprehensive infection prevention and control program that includes surveillance, staff training, and standardized policies for device reprocessing.

Citation

TJC IC.05.01.01

The hospital’s governing body is accountable for the implementation, performance, and sustain...

The hospital's governing body is responsible for providing the resources and oversight necessary to ensure the infection prevention and control program is effective and sustainable.

Citation

TJC IC.06.01.01

The hospital implements its infection prevention and control program through surveillance, pr...

The hospital must implement active surveillance, outbreak management, and staff health protocols to prevent the transmission of infectious diseases.

Citation

TJC LD.11.01.01

The governing body is ultimately accountable for the safety and quality of care, treatment, a...

The governing body is responsible for the hospital's legal conduct, medical staff oversight, grievance processes, and quality assessment programs.

Citation

TJC MM.18.01.01

The hospital establishes antibiotic stewardship as an organizational priority through support...

The standard addresses leadership, coordination, documentation, training, guideline adherence, and tracking for a hospitalwide antibiotic stewardship program.

Citation

TJC NPG.05.01.01

The hospital implements its infection prevention and control program through surveillance, pr...

The hospital must implement an infection prevention and control program by identifying and reviewing risks for infection, contamination, and exposure.

Citation

TJC NPG.05.02.01

The hospital implements processes to support preparedness for high-consequence infectious dis...

The hospital must implement protocols for identifying, isolating, and managing high-consequence infectious diseases, including staff training and infection control measures.

Citation

TJC NPG.05.03.01

The hospital complies with either the current Centers for Disease Control and Prevention hand...

The hospital must implement a hand hygiene program that adheres to current Centers for Disease Control and Prevention or World Health Organization guidelines.

Citation

TJC NPG.09.03.01

The hospital investigates adverse events related to tissue use or donor infections.

Requires the hospital to have a written procedure for investigating tissue-related adverse events, reporting to suppliers, sequestering suspect tissue, and informing recipients of donor infection risk.

Citation

TJC NPG.12.01.01

The hospital’s leadership team ensures that there is qualified ancillary staff required to me...

Hospital leadership ensures adequate qualified ancillary staff across service lines, including medical records, dietetic, pharmacy, infection prevention, and surgical services, with specified qualifications and supervision.

Citation

TJC NPG.12.05.01

The hospital provides education and training and evaluates staff competence.

Requires the hospital to orient staff, provide ongoing education, and evaluate staff competence at least every three years.

Citation

TJC NPG.14.06.01

The hospital has an active antibiotic stewardship program.

Requires the hospital to maintain an active, multidisciplinary antibiotic stewardship program that monitors antibiotic use.

Citation

TJC PE.04.01.05

The hospital has a water management program that addresses Legionella and other waterborne pa...

Requires the hospital to maintain a water management program addressing Legionella and other waterborne pathogens, including a responsible individual or team, a risk management plan, monitoring protocols, corrective actions, and annual program review.

Citation

TJC PI.12.01.01

The hospital collects data.

Requires the hospital to collect, analyze, and act on data regarding medical errors, adverse patient events, and quality improvement projects.