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The Joint Commission Audit: Are You Ready?

January 08, 2019



As we approach the one year anniversary of the Joint Commission’s decision to place an increased focus on hand hygiene behavior among healthcare staff, what have you done to better prepare your facility for its next audit?


Before the January 2018 update, healthcare workers observed failing to perform hand hygiene during patient care weren’t cited as long as their facility had an existing hand hygiene compliance program in place. After the update, the Joint Commission began citing these failures with a ‘deficiency.’


This was a significant change as it meant the accreditation status of hospitals nationwide now depended on hand hygiene compliance. It also meant an increased opportunity for these hospitals to increase patient safety, enhance quality of care and improve economic outcomes.


So, back to our question: What have you done to better prepare your facility for its next audit? Is your facility ready?


We recently sat down with Connie Steed, MSN, RN, CIC, FAPIC, Director of Infection Prevention at Greenville Health System – a facility that has been through (and passed) a Joint Commission survey after the update – to get some insider tips on what the Joint Commission is focusing on and what healthcare facilities can do to better prepare.


According to Steed, the Joint Commission is currently more focused on infection prevention and hand hygiene than ever before. In fact, two of the ten most commonly cited standards within the first six months after the update focused on these topics. Those standards are:


  • Third most cited (74 percent): IC.02.02.01 “The hospital reduces the risk of infection associated with medical equipment, devices and supplies”
    • Non-critical equipment / environmental disinfection
    • Semi-critical equipment / high level disinfection
    • Storing of equipment
    • Following manufacturers instructions for use and cleaning
    • Transport of contaminated instruments


  • Ninth most cited (61 percent): IC.02.01.01 “The hospital implements its infection prevention and control plan”
    • Use of PPE
    • Isolation precautions
    • Outbreak investigations
    • Storage and disposal of infectious waste
    • Reporting of surveillance activities


For more from Steed on what the Joint Commission is looking for, and what your facility can do to prepare for – and pass – an audit of your own, download this complimentary webinar. In it, Steed discusses the specific areas the Joint Commission focused on during GHS’s audit, how her facility drove culture change and increased hand hygiene compliance, as well as tips how to implement improvements of your own.


Click on the button below to access the recorded webinar featuring Connie Steed, the Joint Commission Survey Preparation Checklist and other resources to help you improve hand hygiene awareness at your facility. Simply complete a small form and these helpful resources will be at your fingertips!



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