The Joint Commission’s New Hand Hygiene Standards and What You Need to Know to Stay Compliant

Updated: May 7, 2019



As of January 1, 2018, if a Joint Commission surveyor sees just one clinician fail to clean his or her hands while in the process of direct patient care, the hospital will be cited with a deficiency, resulting in a Requirement for Improvement under the Infection Prevention and Control chapter for all accreditation programs. One missed hand-hygiene opportunity will likely trigger a second survey and could jeopardize a hospital’s accreditation. Learn about the origin of these standards from the Joint Commission, why they recently changed and actions needed to stay compliant for this year's audit.


National Patient Safety Goals—Hospital-Associated Infections

Medical errors have recently been cited as the third leading cause of death in the United States. In response to this crisis, the Joint Commission, a non-profit that certifies and accredits healthcare organizations throughout the U.S., has instituted a number of National Patient Safety Goals. One of these seeks to address the most common, expensive and preventable type of patient safety error: healthcare-associated infections (HAIs).


HAIs are a worldwide problem, affecting hundreds of millions of people each year, according to the WHO. The Joint Commission states its case plainly: over 2 million patients per year contract an HAI, and 99,000 of these patients die from their infection. Among the causes of HAIs, one stands out above all the others: poor hand hygiene. Improving hand hygiene is critically important for reducing pathogen transmission between clinicians and patients. As part of its National Patient Safety Goal of reducing the risk of HAIs, the Joint Commission is therefore working to bring hand hygiene practices in U.S. hospitals to the level of the current guidelines of the CDC and WHO. Towards this goal, it has not only provided specific guidelines for hand hygiene, but also seeks to foster a "culture of hand hygiene." Part of the method for accomplishing this is regular compliance monitoring.


Why Assessment of Hand Hygiene Is Necessary

It is common knowledge that microorganisms are transmitted by unwashed hands. This understanding goes back over 100 years, to the observations of Dr. Ignaz Semmelweiss in the 19th Century that handwashing saved women from dying of infections during or after childbirth. However, despite this knowledge, an alarming number of today's healthcare workers do not adhere to recommended handwashing practices, with as high as 60 percent of healthcare workers foregoing proper handwashing.


Clues to the reasons underlying this behavioral paradox can be found in specific conditions that have been associated with poor handwashing compliance. These fall into a few different categories. These are:

  • Time pressure: understaffing, patient crowding, weekday shifts and lack of institutional priority are all associated with poor handwashing.

  • Inconvenience, including a lack of soap, paper towels, or convenient sinks.

  • False beliefs or lack of education, including the belief that the risk of acquiring an infection from a patient is low, the belief that handwashing is not necessary if gloves are worn, and a general lack of knowledge or skepticism about the value of hand hygiene guidelines.

Importantly, a lack of role models can mean that certain cultural groups engage in poor handwashing practices; for example, nurses are more likely to be compliant with handwashing standards than physicians and nurse's assistants, and female healthcare workers are more likely to be compliant than males.


Finally, there is the simple phenomenon of forgetfulness—many healthcare workers simply don't remember to wash their hands. The only effective way to address all the reasons behind poor hand hygiene practices is monitoring.


The New Standards of the Joint Commission

Starting in 2004, the Joint Commission introduced the National Patient Safety Goals, or NPSG, for reducing HAIs. For hand hygiene, the following were required:

  • a hand hygiene program

  • goals for improving compliance with the program

  • monitoring of the success of those plans

  • improvement of the results through appropriate actions

Individuals failures, however, were not cited as deficiencies, if a program was in place and compliance was improving. This changed in 2018, following the rationale that there has been enough time for healthcare organizations to implement hand hygiene programs. Essentially, the Joint Commission no longer believes there is any excuse for any personnel engaged in direct patient care to fail to meet handwashing standards.


Steps to Ensure that Your Organization is Ready for the Joint Commission Survey

You can take clear action to make sure your organization is in compliance with hand hygiene standards before the Joint Commission surveyors show up at your front door. First, make sure these checklist items are in good order:

  • Are all soap dispensers full and operational?

  • Are all paper towel dispensers filled?

  • Are all lotions approved?

  • Are all alcohol gel bottles full?

  • Are all sinks easily accessible?

Next, the Joint Commission has issued a Hand Hygiene Targeted Solutions Tool, a web-based application that can be downloaded free of charge.


These steps will help get you to a good level of hand hygiene. But, with the new Joint Commission standards, “good” is not good enough. Here are further steps you can take to fortify your organization and help ensure that none of your staff will be cited for hand hygiene failure:

  • Smart Dispensers: Track the amount of soap and sanitizer used to monitor general handwashing rates. Changes in usage can serve as alerts to changes in handwashing compliance. In addition, such dispensers can provide automatic notifications for refills.

  • Workflow Monitoring: Use technology to count every patient room entry and exit, along with hand hygiene frequencies, providing a comprehensive picture of hand hygiene for that room.

  • Individual Reporting: Use technology to track individual hand hygiene events, including information on duration and quality of handwashing. This can be especially important if hand hygiene rates vary substantially between different caregivers.

The Value of Going the Extra Mile

When it comes to saving lives—and retaining accreditation—what is it worth to your organization to make sure you are in compliance with best practices, as well as Joint Commission standards? Do you want to "just pass" or do you want to be certain that your organization is on the forefront of patient safety in terms of preventing HAIs?


To go the extra mile, it is vital to institute your own hand hygiene monitoring and compliance programs. Vitalacy can help through smart, technology-based solutions that support your efforts to bring hand-hygiene failures down to the magic number now expected by the Joint Commission—zero.



Dr. CS Copeland holds a BA in neuropsychology from the University of California at San Diego and a PhD in molecular and cellular biology from Tulane University, specializing in parasitology and virology, with postdoctoral research in molecular entomology and computational genomics.

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