The Joint Commission implemented new hand hygiene rules, effective Jan. 1, that allow surveyors to cite a hospital for a deficiency if an individual fails to perform hand hygiene in the process of direct patient care.

Individual deficiencies will result in a Requirement for Improvement under the infection prevention and control chapter for all accreditation programs.

Surveyors previously were limited to citation for failure to implement and make progress in hospitals’ hand hygiene improvement programs as a whole. The shift to citing individuals for hand hygiene noncompliance comes 14 years after hand hygiene was added as a Joint Commission National Patient Safety Goal, intended to prevent infections.

The Joint Commission determined organizations have had sufficient time to train personnel in hand hygiene, which is an important intervention to prevent health careassociated infections. Hospitals are expected to use hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization to comply with Joint Commission standards.

The Joint Commission also launched a tool to help hospitals measure and improve their hand hygiene performance.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.