It's Survey Time -

One Hand Hygiene Deficiency means

One Very LARGE Citation!

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Podcast – Episode 18

March 12, 2018

Ever wonder what it would take for hospital leadership to finally take hand hygiene seriously?

Well, the Joint Commission may have done it.

As of January 2018, any person not performing hand hygiene during patient care will receive a hand hygiene deficiency! Just one person not doing the right thing will cost your organization, not to mention harm a patient!

From the Joint Commission:

Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards

Beginning Jan. 1, 2018, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care will be cited as a deficiency resulting in a Requirement for Improvement (RFI) under the Infection Prevention and Control (IC) chapter for all accreditation programs. 

Standard IC.02.01.01, element of performance (EP) 2, states, “The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.”

Hand hygiene is widely known to be the most important intervention for preventing health care-associated infections (HAIs). Surveyors also will continue surveying an organization’s hand hygiene program to National Patient Safety Goal (NPSG) 07.01.01.


The Joint Commission introduced this NPSG in 2004. It requires health care organizations to: 

  • Implement a hand hygiene program.

  • Set goals for improving compliance with the program.

  • Monitor the success of those plans.

  • Improve the results through appropriate actions.

In general, surveyors issue an RFI to organizations for failure to implement and make progress in their hand hygiene improvement programs, according to NPSG.07.01.01. With the exception of the Home Care and Ambulatory Care Accreditation programs, observations of individual failure to perform hand hygiene were not cited as deficiencies if there was otherwise a progressive program of increased compliance. Because organizations have had since 2004 to implement successful hand hygiene programs, The Joint Commission has determined that there has been sufficient time for all organizations to train personnel who engage 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.