Are You Ready for The Joint Commission’s NEW Infection Control Chapter?

Coming this July 2024, the standards from the newly re-written Joint Commission Infection Control (IC) Chapter for both Hospital and Critical Access Hospitals will be in effect.  This total revamp of the IC chapter is part of The Joint Commission’s plan to reduce duplicative and non-value-added standards to better align with the Conditions of Participation (CoPs) of the Centers for Medicare & Medicaid Services (CMS).  Additionally, the new standards reflect the guidelines from the Centers for Disease Control and Prevention (CDC) Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings.  The number of Elements of Performance (EP) has dropped from 51 to 14.  Although this may indicate fewer requirements, these changes have more prescriptive expectations for compliance.  Organizations are encouraged to review the upcoming changes in the Joint Commission’s R3 report (Issue 41, December 20, 2023) for specific details.

Emphasis on Competency in Infection Control Procedures

There is a new expectation that the leader(s) of the IC Program oversee a competency-based training and education program for staff on infection prevention and control policies/procedures as they apply to their role/responsibilities. Greater emphasis is placed on the staff’s ability to demonstrate the skills and tasks specific to infection control and prevention. This may be in response to the continued observations during the survey of shortfalls with cleaning and disinfection of critical and non-critical medical equipment and devices.

This may pose a significant lift for organizations without a comprehensive competency program for IC processes.  Organizations are encouraged to review HR.01.01.06 EPs 1,3,5,6 regarding development and sustainment of competencies.  The CDC Infection Control Assessment and Response (ICAR) Tool for General Infection Prevention and Control (IPC) Across Settings can provide a means to assess your organization’s competencies with IC practices to ensure alignment with this new standard.

Policies and Procedures Aligned to a Reference Hierarchy

Additionally, there is a requirement for an organization’s IC policies and procedures on infection transmission to align with an established hierarchy of references.  This would include (in descending order):

  • Applicable law and regulation, including federal, state, and local law and regulations.
  • Manufacturers' instructions for use.
  • Nationally recognized evidence-based guidelines and standards of practice. Without guidelines, expert consensus or best practices would be considered acceptable guidance. (The organization’s policies and procedures must reference these guidelines.)

As an example, there is no mention of the influenza vaccine requirement in the new standards.  However, organizations must follow all vaccination requirements established from the hierarchy of references above.  This makes the requirement more efficient by including all vaccination requirements.  Often, these are mandated at the state level for healthcare personnel.  Organizations must familiarize themselves with the applicable reference sources listed above that guide their activities with infection transmission prevention and ensure their policies and procedures reflect these guidelines.

More Prescriptive Guidelines on Cleaning and Disinfection

New standards are more prescriptive with the content of organizational policies and procedures for cleaning, disinfecting, and sterilizing reusable medical and surgical devices and equipment.  As a result of common survey findings in this category, the Joint Commission expects that IC policies and procedures reflect the incorporation of the Spaulding classification system and manufacturers’ instructions for use and guiding principles.  Furthermore, there are specific requirements related to organizations following the manufacturer’s instructions for use with disinfectants and sterilants, including appropriate dilution, contact time, and application methods.

Additionally, Organizational policies and procedures must indicate the required documentation associated with device reprocessing.  Documentation may include the use of sterilizer logs, chemical, and biological testing frequencies, documentation of chemical concentration during high-level disinfection procedures, how discrepancies are resolved between instructions for use for both devices and equipment used to disinfect those devices, processes and criteria for Immediate Use Steam Sterilization and actions to take with reprocessing errors or failures.  Organizations will need to review manufacturer instructions for use for devices, reprocessing equipment, disinfectant/sterilants, and reprocessing indicators to ensure that the details of their use are reflected in their policies and procedures.  This may pose a significant lift for organizations with more complex and varied disinfection processes.  Organizations must remember that manufacturer instructions for use are monitored for updates, and any changes are promptly communicated to staff and subsequently reflected in policy/procedure documents.

Increased Responsibility Placed on the Governing Body

Additional responsibility is being placed on the governing body in their oversight of the implementation, performance, and sustainability of the IC program, including supporting resources to track the program’s activities. The governing body must ensure the organization’s Quality Assurance and Performance Improvement Program and other key leaders are integral to addressing any problems identified by the IC Program to ensure expeditious mitigation.  This requirement would necessitate that the Governing Body is made aware of the IC program’s activities, including performance metrics and risk assessments.  The transparency of this data should prompt the Governing Body to direct efforts to address risks and challenges to the program.  These initiatives should be reflected in the Governing Body meeting minutes as evidence of their oversight.

Streamlining Implementation of Surveillance, Prevention, and Control Activities

As with the current standards, the organization will need to identify and prioritize its infection-related activities annually and with any significant changes.  The current risk prevention activities for Central Line Associated Blood Stream Infection (CLABSI), Catheter-Associated Urinary Tract Infection (CAUTI), Multi-Drug Resistant Organisms (MDRO), and Surgical Site Infections (SSI) will be rolled under the new overarching surveillance, prevention and control activities based on the annual risk assessment by the organization.

The new IC standards will be more prescriptive with the organization’s implementation of policies and procedures for infectious disease outbreaks.  These changes can be attributed to lessons learned from the pandemic.  Organizations must ensure these areas are reflected in their policies and procedures.  These changes include the implementation of policies that address the following:

  • Implementation of activities when an outbreak is first recognized.
  • Reporting an outbreak by state and local public health authorities requirements.
  • Implementing outbreak investigations.
  • Communicating information to prevent further infection transmission.

New Standard for Dangerous Infectious Diseases

As an additional result of lessons learned during the pandemic, the Joint Commission created a new standard (IC.07.01.01): “The hospital implements processes to support preparedness for high-consequence infectious diseases or special pathogens.”  This new standard does not define what a high-consequence infectious disease or special pathogen is except to say that it can present as a new or re-emerging organism that is easily transmitted from person to person, has limited or no countermeasures, has a high mortality, requires prompt identification and implementation of infection control activities and requires rapid notification to public health authorities.  The expectation is that organizations will develop and implement procedures and policies to address these diseases, including screening, isolation, communication, and other prevention-type activities.  Furthermore, staff must be trained and competent with these procedures and policies.

Organizations should look to their Infection Preventionists and Emergency Management Teams for initial guidance in developing/reviewing their processes. The CDC and the Administration for Strategic Preparedness and Response (ASPR)—Technical Resources, Assistance Center, and Information Exchange (TRACIE) have extensive resources available. Smaller organizations with limited resources may need to contact their State Authorities for assistance. Much was learned from the pandemic that can be used in addressing other high-consequence diseases.


The new Infection Control chapter, which will come into effect in July 2024, reflects the changes learned from the COVID-19 pandemic and the persistent findings by the survey teams regarding infection control processes. Organizations should review the R3 report and compare their policies and procedures with the new changes to ensure alignment.

For questions or to learn more contact the C&A team at 704-573-4535 or email us at

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