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As of July 1, 2024, Joint Commission Accredited Psychiatric Hospitals accredited under the Comprehensive Accreditation Manual for Hospitals, must comply with new and revised infection prevention and control requirements. This overhaul involves a comprehensive rewrite of the Infection Prevention and Control (IC) chapter and will supersede the existing chapter for Psychiatric Hospitals. 

Revised Infection Prevention & Control Requirements

In the realm of healthcare, ensuring patient safety and preventing infections are paramount concerns. Whether accreditation to achieve these objectives occurs through TJC, DNV, CHIQ, or ACHC, a psychiatric hospital’s infection prevention and control program must adhere to a set of essential principles and practices. These principles are vital for safeguarding the well-being of patients. Plus, they protect the healthcare staff and the community at large. In this context, we highlight the essential principles that minimize the risk of infection in a psychiatric hospital environment. 

Essential Principles

Both the governing body and the psychiatric hospital leadership and staff play key roles in achieving the essential principles.

The Governing Body

  1. Appoint an expert infection prevention & control professional.
  2. Ensures that the infection prevention and control program has the resources to conduct operations and accomplish its goals.
  3. The infection prevention and control program has comprehensive written policies and procedures, designed to govern its operations and effectively mitigate the spread of infections, both within the psychiatric hospital and across other institutions and settings.

The Psychiatric Hospital Leadership and Staff

  1. Assesses infection, contamination, and exposure risks that may endanger patients and staff, in order to prioritize program activities.
  2. Implements and documents surveillance activities to prevent and control healthcare–associated infections (HAIs). 
  3. Performs job-specific training, education, and competency validation on infection prevention and control processes. 
  4. Implements a comprehensive program for Standard Precautions to safeguard the health of patients and staff.  
  5. Puts individualized patient transmission-based precautions into practice. 
  6. Establishes policies and procedures for medical device insertion, maintenance, and discontinuation practices.  
  7. Uses policies and procedures to safeguard the health of its staff in accordance with law and regulation.  
  8. Enacts infection prevention practices during hemodialysis procedures.
  9. Process laundry & linen in accordance with law and regulation.
  10. Dietary services and kitchen practices are performed to support the prevention of food borne infections in accordance with the federal, state, and local codes, law and regulation on food operations.
  11. Perform surgical services in conformance to aseptic and sterile techniques.  


TJC, DNV, CHIQ, ACHC, CDC, WHO, APIC and other organizations provide multiple resources to assist Hospitals and Psychiatric Hospitals to develop and implement a robust infection prevention and control program. Get started today to ensure you are survey ready by July 1, 2024.  

The implementation of essential principles within a psychiatric hospital’s infection prevention and control program is imperative for maintaining the highest standards of healthcare. These principles encompass a broad spectrum of measures, from appointing qualified professionals and robust risk assessment to meticulous surveillance and rigorous training. Together, they constitute the foundation for safeguarding the health of patients, staff, and the broader community. By adhering to these principles, psychiatric hospitals not only fulfill their duty to provide the best possible care but also contribute to the broader goal of creating a healthier and safer society.  Get started today to ensure you are survey ready by July 1, 2024.  

Barrins & Associates Consultation

At Barrins & Associates we can assist you to develop a comprehensive infection prevention and control program in adherence to TJC, ACHC, CIHQ,  and DNV standards. Inquire today about our consulting services. We continue to support your journey toward accreditation and regulatory compliance.

Barrins & Associates – Guiding Your Success: Real-World Solutions to Meet Accreditation and Regulatory Challenges.  Contact us to learn more!