The Joint Commission now cites individual hand hygiene noncompliance as deficiency

The Joint Commission announced that starting Jan. 1 if surveyors observe any individual failures to perform hand hygiene in the process of direct patient care, it will be cited as a deficiency. The body will also continue surveying organizations with regard to their hand hygiene programs, as per Patient Safety Goal NPSG.07.01.01.

The deficiency will result in Requirement for Improvement under Infection Prevention and Control Standard IC.02.01.01, EP 2: "The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection." The new rule is applicable to all accreditation programs.

Previously, surveyors issued an RFI for failure to implement hand hygiene improvement programs and make progress in these programs. With the exception of home care and ambulatory care accreditation programs, individual failure to perform hand hygiene was not cited as a deficiency if there was evidence of increased hand hygiene compliance via the organization's program.

However, organizations have had nearly 14 years to implement successful hand hygiene programs, since The Joint Commission introduced national patient safety goal centered on complying with CDC or World Health Organization hand hygiene guidelines. The Joint Commission has determined that organizations have had enough time to train all healthcare workers involved in direct patient care.

"While there are various causes for HAI, The Joint Commission has determined that failure to perform hand hygiene associated with direct care of patients should no longer be one of them," the accreditation body noted in a statement.

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