Joint Commission now citing individual hand hygiene failures

The surgical scrub is routine for surgeons, and, unquestionably, appropriate hand washing before a procedure helps to prevent infection. It’s no great leap, then, to understand that proper hand hygiene is crucial to safe, high-quality patient care—even outside of the surgical suite.

Unfortunately, on average, health care workers clean their hands less frequently than they should, according to the Centers for Disease Control and Prevention (CDC).* The CDC also estimates that one in 25 hospital patients has at least one health care-associated infection (HAI).*

Hand hygiene is widely regarded as the most important intervention for preventing HAIs, which is why The Joint Commission continues to emphasize the importance of hand hygiene.

Joint Commission efforts

In 2004, The Joint Commission introduced National Patient Safety Goal (NPSG) 07.01.01, which requires health care institutions to carry out the following efforts:

  • 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 2008, the Joint Commission Center for Transforming Healthcare started its first improvement project—preventing hand hygiene failures. This project resulted in the first Targeted Solutions Tool (TST) for Hand Hygiene. A TST guides an institution through a step-by-step process to achieve the following objectives:

  • Measure the organization’s actual performance
  • Identify barriers to excellent performance
  • Offer directions toward proven solutions that are customized to the specific institution

Despite these efforts, the most recent data on compliance with hand hygiene standards reveal that of The Joint Commission accredited office-based surgery facilities surveyed as of mid-year 2017, 18 percent were cited for noncompliance with NPSG.07.01.01.

Next steps

Until now, surveyors concentrated on the presence or absence of hand hygiene improvement programs and only issued a requirement for improvement to institutions that failed to implement and make progress with these 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 protocols were not cited as deficiencies if a progressive program of increased compliance was in place.

The Joint Commission maintains that enough time has been allotted to provide training in hand hygiene to health care personnel who engage in direct patient care. With that in mind, since January 1, whenever Joint Commission surveyors observe an individual failure to perform hand hygiene in the process of direct patient care at an accredited program, they must cite the incident as a deficiency resulting in a requirement for improvement under the infection prevention and control chapter.

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

Surveyors will continue to cite the NPSG when evaluating an institution’s hand hygiene program.

Resources available

Although various problems cause HAI, The Joint Commission has determined that failure to engage in hand-hygiene practices during direct care of patients should no longer be one of those factors.

The Joint Commission offers several resources to improve programs and individual compliance in the area of hand hygiene, including the Infection Prevention and HAI Portal. In addition, the TST for Hand Hygiene is available free of charge to all accredited organizations.

Questions about the standards should be directed to the TJC Standards Interpretation Group at 630-792-5900 or via online submission form.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. Available at: Accessed January 23, 2018.

The Joint Commission. Accreditation and Certification. Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards. Available at: Accessed January 23, 2018.

Tagged as: , ,


Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611


Download the Bulletin App

Apple Store
Get it on Google Play
Amazon store