Infection Prevention planning for The Joint Commission (TJC)

By Mark Ingerman, MD & Eileen Sherman

TJC is planning visits to all five facilities of the Main Line Health System (MLHS) in the near future. These visits are unannounced surveys. There are several TJC standards from an Infection Prevention (IP) standpoint. The following are areas that will be highlighted for TJC strategic reviews.

  1. Hand Hygiene and Isolation: TJC standards require that all facilities maintain 100% compliance regarding hand hygiene. Please assure that all healthcare personnel comply with MLHS hand hygiene policies. This includes performing hand hygiene before and after leaving a patient’s room or having patient contact. TJC will cite any institution that does not maintain 100% compliance.

In addition, please abide by all isolation protocols. Isolation signs are maintained on the exterior of any patient’s room that requires a specific type of isolation. Whether the isolation is for droplet precautions, airborne precautions, contact precautions or special contact precautions, please maintain strict compliance with these policies. TJC will cite any deviations from the standard of care.

  1. Antimicrobial Stewardship (AMS): MLHS has a robust antimicrobial stewardship (AMS) program. This is a standard in which our system complies with the TJC. The choice of antibiotic therapy, as well as the duration of these medications, is monitored on a regular basis by infectious disease pharmacists, as well as general pharmacists educated in AMS. These pharmacists review the antibiotic usage throughout the MLHS on a regular basis. AMS education has been disseminated to system and campus CEWs and COCs.
  2. Device utilization: The Infection Prevention goal is to eliminate possible healthcare-associated infections (HAI) such as CAUTI, CLABSI, C. diff , SSIs, and VAPs. The most important element in preventing certain HAI is the removal of unnecessary devices such as central lines and Foley catheters when no longer clinically indicated. The more rapid these devices are removed, the less likely a patient will acquire a HAI which prolongs their hospital stay and increases the overall morbidity of the patient.

Our goal from an IP standpoint is to limit any infectious risks to our patients, improving the quality and safety of their stay at MLHS.

Should you have any questions, please contact either Dr. Mark Ingerman or Eileen Sherman.


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