The Joint Commission standards function as the foundation for healthcare organizations to

gauge and enhance their performance. These standards focus on quality care and patient safety.
The Joint Commission develops standards criteria based on feedback and interactions with
consumers, healthcare professionals and government agencies. The standards go through a
comprehensive development process, which includes conversations with advisors, preparation
of draft standards and reviews by outside experts. Prospective standards are also published on
the Joint Commission's website and made available for public comment before being approved
by the group's board of commissioners. The joint commission standards include several
different areas, however in this paper I will be focusing on infection control.

Infection control is a significant perspective in the conveyance of healthcare as it identifies with

patients, guests and staff. Patients enter to the hospital with the aim to improve or balance out
their present wellbeing status. Guests enter the hospital to either direct business or give
passionate help to their friends and family. and the employees enter to the hospital to serve
everyone within the hospital with appropriate care and provide a clean environment to them. It
is important for the leadership and employees to utilize broadly proven infection control
standards to provide such environment.

According to the attached table that conducts the four areas that needs to be reviewed, the
next expected visit to the hospital, from the joint commission is in 13 months. Therefore, the
first step in this report is to review the joint standards commission that related with infection
control.

1. IC.02.01.01 Surveillance, to minimize, reduce, or eliminate the risk of infection.

2. NPSG.07.01.01 Hand hygiene guidelines

3. NPSG.07.03.01 prevent health care–associated infections due to multidrug-resistant

organisms in acute care hospitals.
4. NPSG.07.04.01 implement evidence-based practices to prevent central line–

associated bloodstream infections

5. NPSG.07.05.01 Implement evidence-based practices for preventing surgical site

Infections.

According to the infection control report, there is a deficiency with central line blood stream
infections. As the rate of infection goes up in March, and at the other side, the rolling rate
started moving slowly in July. Then again, the infection rate goes up continuously in August and
September, and as result from that, the rolling rate keep increasing from July to September, and
yet the infection rate goes down in October and endured the same rate till December which is
the end of the year.

Regarding to the Hand hygiene report, there are four compliance that need to be compared
with the previous year. first for Hospital-Wide the report showed that, there is an overall decline
comparing with last year. then Nursing and Ancillary, the report showed that, both compliance
remined the same rate without any changes between the years. Lastly, physician, as the report
it showed there is an improvement comparing to the last year, as it moved from %91 to %94.

In addition, the data chart for Central Line Bundle Compliance showed that, there is slight
difference between the first and second quarters as it increased from 84 to 85. It also showed
that, the compliance increased be hug amount in the third quarter as it moved from %85 in the
second quarter to 95 t 97 in the third quarter. However, this was not the same scenario at the
fourth quarter, as there was great decline in the compliance from 97 to 83, which is even lower
than the first quarter.
There are some areas that need to be monitored, such as the surgical site infection, as the total
knee replacement was greater than the other hospitals that got similar procedure. Which mean
that, the surgical site infection rate got greater procedure than the comparable hospitals
procedure.

Moreover, the NNIS risk index were used in order to determine patients with high risk, and the
result showed that, there is increase in the surgical site infection rate comparing with the
highest patient’s risk at the other hospitals.

1. Plan for compliance for Hand hygiene, the hospital should utilize proper hand washing
tools in order to avoid the infection around the hospital from patient to another. Make
sure that, every employee washing their hand regularly based on the hospital policy and
procedure. Employees who responsible for surveillance are the main director of nursing,
facilities managers, risk managers and charge nurses, need to ensure that all staff would
wash their hand and change their gloves after any direct contact with patients.

Changing the gloves after every direct contact with patient is really important as it reduce the
chance of getting infection for patients and staff as well. Also, its important to make sure that,
there is hand wash station in every line at the hospital, so that individuals can reach them easily.

2. Plan for compliance for Multidrug-Resistant Organisms, as the report showed that, there
is no deficiency regarding to this infection area, hence full compliance has been
maintained for this area. As all the rates related with Resistant Organisms have declined
from the beginning of the year and remained at low rate till end of the year.

3. Plan for compliance for central line-associated with bloodstream infection, this
prerequisite covers short and long-term focal venous catheters and incidentally
 embedded focal catheters lines, office wide reconnaissance for a year. With execution of
infection decrease procedures covering six-sigma project.

4. Plan for compliance for creating a sterile filed, implementation of practice for preventing
surgical site infection:

As mentioned in above, the surgical site infection rate succeeding a total knee
replacement higher than the rate of the comparable hospital, therefore the hospital
needs to supervise the SSI rate following these procedures. A recommendation to
implementing a system to ensure that appropriate peri-operative antimicrobial agents
are administered within one hour prior to incision. In addition, weight-based dosing for
obese patients and re-dosing of antibiotics for prolonged procedure may help reduce
rate of SSI