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Preparing Your Ultrasound Department for the Joint Commission

If the thought of the Joint Commission showing up at your ultrasound department’s door sparks anxiety, you are not alone.
The Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JACHO), is an independent, not-for-profit organization that accredits and certifies health care organizations. The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Their accreditation is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Joint Commission Accreditation Survey

The Joint Commission is laser-focused on infection prevention and performs random unannounced surveys that typically occur every 2-3 years.

Since there is no way to know in advance when the Joint Commission will be visiting your facility, the only way to prepare is to maintain good infection control practices throughout the year.

The following tips were compiled from feedback from sonographers at health care facilities across the United States and should be used as a general guide to help your ultrasound department prepare for your next accreditation survey.

Avoid Using ‘Reusable’ Gel Bottles

If your department is still using a 5-liter container to refill your bottles, it may be time to update your infection control procedures, as it could put your facility at risk for being ‘non-compliant’ with the Joint Commission.

The practice of refilling ultrasound gel into ‘reusable’ 250ml bottles has been associated with an increased risk of cross-contamination. This is mainly due to the bottles and gel being exposed to multiple patients and the increased handling during refilling. There also isn’t an efficient way to disinfect the bottles prior to refilling. 

Avoid using 5-liter containers and reusable gel bottles, as they are associated with increased risk of cross-contamination.
Dated Ultrasound Gel Bottle with Open Date and Expiration Date

Date When Ultrasound Gel Bottles Expire

Your department should have a procedure in place to identify when an ultrasound gel bottle expires. General industry guidelines state that opened ultrasound gel bottles should expire 28 days after opening for infection control purposes, although the exact timeframe may vary depending on your facility. Some facilities will date their bottles with an “open” date, “expiration” date, or both. Make sure to check with your Infection Control Department to see which method they prefer.

Sonographer Tip: Ask Siri “what day is 28 days from today?” for an easy way to calculate the expiration date.

Keep a Temperature Log When Using Gel Warmers

If your department is using an ultrasound gel warmer, it is good practice to keep a daily temperature log. If your gel warmer doesn’t have a digital display, place a thermometer with a probe on it into the warmer so you always know what temperature your gel warmer is set at. Contact your gel warmer manufacturer for the operating instructions so you know the maximum temperature it can reach, and ensure all staff are educated on how to safely warm ultrasound gel.

Sonographer Tip: Place a temperature adhesive strip on your ultrasound gel bottles to help indicate the temperature of the gel.

Sample Temperature Log for Gel Warmer Use

While preparing for the Joint Commission can be time-consuming and stress-inducing, following good infection control practices on a day-to-day basis will help your facility’s next accreditation survey go smoothly. If you have questions on our products or how to prepare for the Joint Commission, contact us today.

Want to learn from other facilities’ downfalls? Each year, the Joint Commission publishes a list of the top non-compliant standards from inspections during the previous year in its “Perspectives” newsletter.

These are general guidelines. Your internal facility guidelines supersede any recommendations made.

Want to avoid the infection control headache that comes with preparing for the Joint Commission? Make the switch to single-use packets.

By switching to single-use packets, your ultrasound department can enhance your infection prevention strategy and help reduce the risk of cross-contamination without the additional steps required for bottles or other multi-use gel products.