The Joint Commission’s 4-1-1 on Survey Enhancements Related to SPD

Late last year, The Joint Commission (TJC) announced an improvement to their on-site surveys, calling it 4-1-1 Survey Enhancements.  TJC surveyors are now instructed to take a deeper look at four high-risk areas that pose the greatest risks to patients if they fall short.  The four areas are:

  • High-level disinfection (HLD) and sterilization,
  • Sterile medication compounding,
  • Suicide prevention, and
  • Hemodialysis.

I was glad to see the 4-1-1 on Survey Enhancements and not surprised that high-level disinfection and sterilization was one of the four areas highlighted. TJCs Infection Control (IC) standard IC.0.02.01 requires healthcare facilites to reduce risks of infections associated with medical equipment, devices and supplies.  This IC standard is one of the most regularly cited non compliance standards.

TJC Survey enhancement revisions are setting their focus on the processing steps that pose the highest risks to patients if they fail.  These survey enhancements went into effect on September 1, 2018. The emphasis appears to be on ensuring facilities follow evidenced based guidelines such as AORN, AAMI, CDC and APIC and strictly adhering to the manufactures instructions for use.  Many facilities were historically cited for things that were the “interpretations” of the particular surveyor.

The 4-11 publication states that they previously cited if there was visible bioburden and dried blood found on instruments, they also used to score if an enzymatic solution was not applied to maintain moisture on instruments.  However, that is not specifically what the current, AORN or AAMI guidelines state.  I am glad to see the new TJC scoring would only happen if the facility did not have a process for keeping used instruments moist. That is clearer and does not routinely mandate the use of an enzymatic solution.  Now TJC states that surveyors will score if “wiping/flushing of soiled instruments is not observed during a case in the OR or procedure room and it is clinically appropriate.”

Another new guidance in the 4-1-1 is on transportation of contaminated instruments.  Before surveyors would cite a facility if any instruments were NOT transported from point-of-use in a leak-proof puncture-resistant container with the biohazard symbol or color red. Now TJC makes it clear that non-sharp items may be transported in a way that does not lead to contamination of staff or others. However, they still need to be in a biohazard labeled or red container according to OSHA.

Historically TJC scored if endoscopes exceeded hang time.  Now they say organizations must follow the manufacturer’s IFU for drying and frequency of reprocessing.  They will NOT routinely score findings related to hang time.  Although if that is already in your hospital policy, I can imagine they will still score it if you are not following your own policy.

It seems to me they are headed in the right direction and I think organizations will be cited less, especially if surveyors are trained to new expectations and current standards and guidelines.


The Joint Commission. 4-1-1 on Survey Enhancements: New scoring revisions for IC.02.02.01 now in effect, posted 9/5/2018. Accessed 12/27/2018. Available at

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President/CEO Seavey Healthcare Consulting, LLC 

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