You don’t have to be smart to be a surveyor

This list comes out from Joint Commission pretty regularly, twice a year maybe.  It’s the top ten standards that they cite on survey.  Infection control is always there somewhere.   And it sure does stink to be the Facilities director, because most of the rest is Environment of Care.   What strikes me most about the infection control and some of the EOC is that these are easy finds.  You can see them without looking very hard: you really don't have to be some highly-trained scientist or surveyor. For that reason, they should be the issues you see also when you make rounds.

If you are new to Infection Control, there really isn’t a lot of learning time, especially if you work alone.  You need to hit the ground running.  It’s nobody’s problem but yours that you started on the 3^rd day of the month and your monthly or quarterly committee reports are due on the 7^th.  Or that the person who left your job gave 2 weeks’ notice and has been gone for 6 weeks, since a job search takes so long. And that doesn’t even include your mandatory/regulatory reporting.  You probably haven’t left your office since day one.  But you have to.

I learn more by walking the unit than I ever do by perusing the literature, following headlines on Twitter or going to conferences.  What I learn by walking is what the real risks and regulatory risks are in my facility. The second most common TJC IC finding is not developing and implementing an infection control plan specific to your facility.   How can you plan your activities and interventions if you don’t know what the issues are?  Go walk.

I enjoy an early morning stroll, at change of shift, when food trays are being delivered, clinical staff is visiting patients, and morning care is being provided.  I like 7 a.m glucose checks, 8 a.m. med passes, breakfast dining groups, and the setup of the OR for the day.  I like to see the remnants of the night: how much trash or laundry accumulated in soiled utility rooms, food left at the nurses’ station, and fake fingernails on people who never see a supervisor.  Everything that I see, a surveyor sees, too.

I'm a little torn about whether we should expend all our efforts just to satisfy an accreditation agency (like teaching to the test), but I do think they have laid out some very good standards for running a safe facility, and I think that makes it worthwhile work.  If you are TJC accredited, IC 02.02.01 is a number you should know like your Social Security number.  This is the standard that says patients don’t get infections from any of the stuff here (medical equipment, devices, and supplies).  While some of it relates to sterilization, which is more complex, much of it refers to general equipment and supplies. This means stuff is clean and Once Clean,Kept Clean.  How do you clean it?  How do you know it’s clean? How do you keep it clean?  This standard melds nicely with the EC standard for blocked egresses (stuff in the hall blocking fire routes or exits).   If you’ve got stuff in the hall, you’re weak on both of these standards.  There is a process that is not in place.

What is that stuff?  IV poles, extra beds, little linen carts?  Is that stuff clean, ready for the next patient use?  How do you know?  Even if it is clean, how long can it stay there before a) it’s no longer clean, or b)you’re violating fire code and impacting safety?  Is it marked to show that it’s clean, or is it in a designated clean area?  These are all easy questions, and easy findings for a surveyor because THEY CAN SEE IT.

Some TJC standards are more obscure.  Patient Rights and Provision of Care standards require chart reviews, staff interviews, and deep thought.  Not infection control—if it’s dirty, everyone can see it.   The same goes for damaged equipment.  I do some work in a therapy facility.  Lots of mats and bolsters and pads.  Lots.  Any rip or puncture is fodder for a citation.  We get plenty of damage from all of the adaptive equipment patients have.  Once an upholstered piece is damaged, it needs to be repaired or replaced, because dirt or liquid can get into the cushion, and there’s always some horror story about a patient that sits on something only to have the prior patient’s body fluids ooze out (this might be IC urban legend, but I have no doubt it did happen somewhere).   We are about to try CleanPatch (an approved patching system for mattresses, etc.  I don’t promote any product or represent anyone, just telling you what I’m doing).  I’m excited to try it.  Duct tape is NOT a solution. The patch is good for a year, which gives you time to work the re-upholstery or replacement cost into your budget for the next year.   Rips and tears are easy to see, and if you have tape holding things together or covering rips, that's not good.

Do I think little punctures are a big deal in my outpatient settings, where the patients are fully clothed, and sometimes their shoe tears a spot near where other people’s feet will go?  No.  But that’s the difference between Real Risk and Regulatory Risk.  Real risk is low in that case, but it’s an easy finding for a surveyor.  Another easy one is the base of an IV pole: sometimes these poles get a quick wipe before going into the closet, but stuff drips all over the base.  Gross.  Probably real risk.  And easy to see.

Tape is another easy find.  Sometimes respiratory or physical therapy will put a cute little piece of leopard-print duct tape on the floor to mark distance for exercise tolerance or walking.  But the edges are adhesive and they trap dirt and you really can’t clean it.  Tape is bad.  I once worked in a LEAN facility, where they improved efficiency and process sometimes by marking stuff with tape—like squares on the floor where certain supplies go, or a counter top (imagine outlining the place where your stapler goes in red tape on your desk).  Apparently nobody spoke to Infection Control.  If you put tape on stuff, you can’t clean it well.  So they had implemented this enormous process improvement system throughout the whole organization, and, well….awful.

Watch your nursing assistants checking blood sugars in the morning.  Are they cleaning the glucometer between patients?  The real risk here is very real.  Make sure it’s happening.  Peek into supply rooms.  If you work in a small facility or clinic, the infrastructure for materials or supply management may not be strong.  Expired supplies are a big deal.  Easy to find, you just check the expiration dates.  No-brainer.

The other benefit to walking is that staff do ask questions once they see you and get to know you.  Sometimes it leads you down a rabbit hole of infection control violations, but I try to look smiley and non-threatening so they do approach.  “Are you the Infections Nurse?” Cringe. Yes, I say.  I learn a lot.  Most of which I later wish I didn’t know.

So go be the surveyor.  You may find that the “big” stuff that we associate with serious illness, like central line infections and VAPs are practically non-existent in your facility, but the little things, lots and lots of little things, are the real problem.  And they will sink your accreditation ship, sometimes for good reason: real risk to patients.