The Joint Commission determines and sets goals for each year, which traditionally mirror federal expectations for healthcare. These goals generally highlight specific safety concerns that are problematic and affect healthcare systems nationwide. For 2016, hospital goals include patient identification, communication, medication safety, alarm safety, healthcare associated infection, falls, pressure ulcers, risk management and universal protocol (TJC, 2016). Within each goal are sub-goals that further address the concerns and identify evidence based practices to ensure success in the prevention of patient harm in each of these areas. During tracers, the auditors focus on these goals and are looking to validate that each of these goals is achieved through implementation of policies and procedures and they will review the processes in which these policies and procedures were implemented and checked for continuous …show more content…
In particular, NPSG 07.06.01 focuses on the prevention of catheter associated urinary tract infections (CAUTIs). Under this guideline, Joint Commission outlines three elements of performance that must be validated for compliance during a Joint Commission survey. First, indwelling catheters must be inserted according to evidence-based guidelines which include limiting the use and duration of indwelling catheters as well as inserting them using aseptic technique. Second, the indwelling catheters must be maintained using evidence-based guidelines which include maintaining a closed, sterile system, securing catheters and allowing for unobstructed flow and replacing collection system, as needed. Finally, health care facilities must monitor for catheter associated urinary tract infections, as well as develop and track prevention processes and outcomes (TJC, 2016). Combined, these elements of performance comply with evidence-based practice guidelines outlined in the HICPAC (spell this out) document Guideline for Prevention of Catheter-associated Urinary Tract