Influenza Vaccination: New Infection Prevention and Control Standard

The Joint Commission is aware that many accredited organizations have not provided influenza vaccinations to staff and licensed independent practitioners in the past.  Therefore, it determined that the requirements of standard IC.02.04.01 will be implemented in the following phased approach for those organizations for which standard IC.02.04.01 is new.  This implementation will provide organizations additional time to set goals and improve their vaccination rate.

Key factors to help you stay compliant with the changes to this standard include:

●Establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff.

●Educate licensed independent practitioners and staff about at minimum the influenza vaccine, non-vaccine control and prevention measures and the diagnosis, transmission and impact of influenza.

●Offer the influenza vaccination on site to licensed independent practitioners and staff or facilitate their obtaining the influenza vaccination off site.

●Include in the Infection Control Plan the goal of improving influenza vaccination rates.

●Collect and review the reasons given by staff and licensed independent practitioners for declining the influenza vaccination.  This collection and review occurs at least annually.

●Provide influenza vaccination rate data to organization leaders at least annually.

This is how I am going to tackle this because I currently just signed a surgery center in which is up for RE-accreditation with the Joint Commission and since the standard states that the JC is aware that influenza has not been offered or provided in the past  you can take a phased approach:

  1. I would add to the Infection Control Plan the above referenced items.
  2. Create an in-service in which is mandatory for all licensed staff and personnel to attend.  The in-service will be documented and contain information about the following:
    1. A definition of the influenza virus
    2. Vaccination recommendations
    3. Prevention measures
    4. Transmission and Impact of the virus
    5. Influenza surveillance and data collection
  3. After 2 (1-5) is discussed I would have the Medical Director take a hand count of who would like to have the influenza vaccination at the surgery center.  Once head count is retrieved the vaccination will be ordered.  (After the fact, once vaccination has been given, documentation will go in the health information section of the individuals credentialing file and human resource file).
  4. For those who declined I would also have attached to the in-service an influenza waiver and attestation sheet for the individual to sign-off on immediately and placed in the health information section of the individuals credentialing file or human resource file.
  5. Start keeping track of the vaccination rate by creating a simple log to be reviewed on an annual basis.  Check back with the CDC website to obtain surveillance recommendations for the center and document you are doing so.

All of this information for you to prepare your in-service is on the CDC website for healthcare workers and influenza which provides you with all of the key information to be in compliance with this standard.

Go to


As part of the Infection Control Plan this in-service is a direct link to the Quality Improvement of the center in which reports to the Governing Body (document the in-service in your QAPI evaluation).

Here’s to your success,


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