Infection preventionists looking to hone compliance with The Joint Commission’s accreditation standard requiring antibiotic stewardship may find some guidance in these answers to frequently asked questions. The answers were posted¹ by The Joint Commission to common questions about the standard.

Q. How will surveyors evaluate that an organization’s leaders have established antimicrobial stewardship as an organizational priority?

A. During the Leadership Session, leaders should be prepared to discuss how they have established antimicrobial stewardship as an organizational priority. Surveyors may ask to review documents related to antimicrobial stewardship such as strategic plans, budget plans, and performance improvement plans.

Q. What type of documentation is needed for MM.09.01.01, EP 5, the required core elements of the antimicrobial stewardship program?

A. The organization must have a document indicating how each core element is addressed in its antimicrobial stewardship program. This information can be located in a separate document or can be included in other antimicrobial stewardship documents (see MM.09.01.01, EP 1). This documentation does not have to be provided in a lengthy format but must describe how the core elements are addressed in the antimicrobial stewardship program.

Q. What type of antimicrobial stewardship data should organizations collect, analyze, and report?

A. The Joint Commission is not requiring any specific antimicrobial stewardship data in Standard MM.09.01.01. The organization must determine the antimicrobial stewardship data it will collect, analyze, and report. The CDC’s Core Elements of Hospital Antibiotic Stewardship Programs (available at: http://bit.ly/2tv6rmo) and the Checklist: Core Elements of Antibiotic Stewardship for Nursing Homes (available at: http://bit.ly/2ArDQhL) provide examples of measures that can be used to collect antimicrobial stewardship data and should be considered by organizations. Additionally, the National Quality Partners Playbook on Antibiotic Stewardship in Acute Care provides examples of basic, intermediate, and advanced measures (available at: http://bit.ly/2iEIL4w).

Q. Will Joint Commission surveyors review human resource records and medical staff credentialing and privileging records to determine if antimicrobial resistance and antimicrobial stewardship education were provided by the organization?

A. Joint Commission surveyors will not be reviewing staff or medical staff/licensed independent practitioner records on education received regarding antimicrobial resistance and antimicrobial stewardship. Joint Commission surveyors will inquire about the type of education provided by the organization during the Medication Management System Tracer (or other system tracers). During patient tracers, surveyors may ask staff and licensed independent practitioners about the education they have received. Providing written material such as the organization’s antibiogram will meet the educational requirement of MM.09.01.01, EP 2.

Q. Are there any specific improvement opportunities that surveyors will look for regarding the organization’s antimicrobial stewardship program?

A. During the survey, organizations must identify improvement opportunities based on their collected and analyzed data. Surveyors will ask the organization to discuss the antimicrobial stewardship improvement opportunities it has identified and the actions taken to improve its program. This information should be documented. If the data demonstrate that antimicrobial stewardship improvements are not necessary, the organization should share these data with the surveyor.

Q. If an organization does not have an infectious disease physician on the antimicrobial stewardship multidisciplinary team will it receive a Requirement for Improvement (RFI)?

A. This depends on the availability of infectious disease physicians to serve in this capacity. The Joint Commission is aware that the composition of this multidisciplinary team may vary based on the type of organization being surveyed as well as the geographic location of the organization. This is the reason MM.09.01.01, EP 4 indicates that the four practitioners listed should be on the multidisciplinary team “when available in the setting.” However, it would not be acceptable for an organization to have a team consisting of only a pharmacist and a nurse when physicians and other licensed independent practitioners are available in the organization (e.g., an infectious disease consultation team exists).

Note: Some organizations such as critical access hospitals and nursing care centers may not have the Medication Management System Tracer. In these cases, antimicrobial stewardship will be evaluated during other scheduled activities, such as Orientation to the Organization, Data Use System Tracer, and Individual Patient Tracers.

REFERENCE

1. Joint Commission. Standards Interpretation: Frequently Asked Questions (FAQs). Available at: http://bit.ly/2k4d5sl.