Compliance News: Influenza Vaccination Standard Revised by TJC

By Dean Samet, CHSP




In their December 2011 edition of The Joint Commission Perspectives, TJC announced their Infection Prevention and Control (IC) Standard IC.02.04.01 would be revised, strengthened, and extended to all TJC accreditation programs in which the standard is not currently applicable. The revised IC changes for hospital, critical access hospital, and long term care accreditation programs will be effective July 1, 2012. The revised IC changes for ambulatory care, behavioral health care, home care, laboratory, office-based surgery, and Medicare/Medicaid certification-based long term care accreditation programs will be implemented in a phased approach commencing July 1, 2012.


Revised Standard IC.02.04.01 elements of performance (EPs) will require accredited organizations to:

1. Establish an influenza vaccination program.
2. Educate licensed independent practitioners and staff about influenza vaccine; nonvaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza.
3. Offer vaccination against influenza to licensed independent practitioners and staff and provide the vaccination at accessible sites and times.
4. Include in their infection control plan the goal of improving their influenza vaccination rate.
5. Set incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.
6. Have a written description of the methodology used to determine their influenza vaccination rate.
7. Evaluate (at least annually) the reasons given for the declining influenza vaccination.
8. Improve their vaccination rate according to their established goals at least annually.
9. Provide influenza vaccination rate data to key stakeholders at least annually.

If organizations are accredited under more than one accreditation program, it is important they review TJC program-specific requirements for each. It is also important to note that Standard IC.02.04.01 does not mandate influenza vaccination for licensed independent practitioners and staff as a condition of The Joint Commission accreditation, nor does it require accredited organizations to pay for the influenza vaccination for licensed independent practitioners and staff.

For program-specific language for Standard IC.02.04.01, go to The Joint Commission Web Site at:
http://www.jointcommission.org/standards_information/prepublication_standards.aspx