Joint Commission Announces New Antimicrobial Stewardship Standard

by dawnconrey

Joint Commission Announces New Antimicrobial Stewardship Standard

by dawnconrey

by dawnconrey

This July 2016 issue of The Joint Commission Perspectives announces the 1/1/17 implementation date for the new antimicrobial stewardship standard, MM.09.01.01. There are 8 elements of performance, the first of which requires that leadership establish antimicrobial stewardship as a priority. Requirements like this are sometimes confusing on exactly how you go about doing this. The good news is TJC supplies a note with this EP stating 6 examples of how leadership can provide evidence of doing this. They include as examples:


  • Accountability documents – in other words a statement of accountability, a charge to a committee or individuals.
  • Budget plans – provide funding and a cost center for the new program
  • Infection prevention plans – the 2017 IC plan could make the implementation of the program a goal, and could even include some planned measurement of effectiveness
  • Performance improvement plans – the 2017 plan could make the implementation an organizational priority.
  • Strategic plans – the board approved strategic plan including the implementation of an antimicrobial stewardship program would sent a strong message.
  • Using the EMR to collect antimicrobial stewardship data – This seems like somewhat of a given, but the 2017 IT budget or goals to make this happen would be one way to show commitment to this new priority.

EP 2 requires the hospital to educate staff and LIP’s about antimicrobial ordering, dispensing, administration, monitoring of antibiotic resistance and the antimicrobial stewardship practices. This education should occur at the time of hire or initial granting of privileges and “periodically” thereafter based on organizational need. Periodically is always a difficult term because of subjectivity on what frequency is sufficient. Since the program will be new in 2017 in most hospitals, and refined during the year before 2018, it would seem reasonable to educate for 2017, and refresh that education with changes to the program for 2018. We would also suggest using an agenda template or training template that specifically mentions the 5 training concepts TJC included in this EP as underlined above.

EP 3 requires education of patients and families regarding the appropriate use of antibiotics. One such mechanism to doing this is a CDC document entitled Viruses or Bacteria, What’s got you sick? The link to that document is:  There is no mention of a D for mandatory documentation, however since patients may not recall that they received any education, having some notation in an education log that the brochure was provided and explained would be a protective measure.

EP 4 sets the requirements for the stewardship team, but does provide a caveat, “when available,” so a small and rural hospital without these resources could have an alternate team membership. TJC suggests an ID physician, infection preventionist(s), pharmacist(s), and a practitioner. TJC also mentions that telehealth consultants could participate on the team as members.

EP 5 establishes the core requirements for the program and these requirements correspond with the requirements published by CDC and NQF. The CDC document can be found at:

The program requirements include:

  • Leadership commitment, and EP 1 explained how to document this.
  • Accountability – Appointing a single leader responsible for program outcomes
  • Drug expertise – Appointing a single pharmacy leader working to improve antibiotic use
  • Action – Implementing recommended actions such as systemic evaluation of ongoing treatment need after a set period of initial treatment, sometimes referred to as the antibiotic “time out.” Here we would advise caution in the development of a grandiose program design, to make sure you are actually capable of doing what you say you are going to do.
  • Tracking – Monitoring the program for prescribing and resistance patterns.
  • Reporting – Regularly reporting information on antibiotic use and resistance to doctors and nurses
  • Education – Takes the education discussed in EP 2 a step further to include education on resistance and optimal prescribing.

EP 6 then establishes requirements for hospital approved protocols which may include formulary restrictions, assessment of antibiotic appropriateness for community acquired pneumonia, skin and soft tissue infection, UTI, C diff, guidelines for adult antibiotic prescribing, pediatric antibiotic prescribing, pre-authorization, and use of prophylaxis. This EP does have a D for documentation.

EP 7 requires the hospital to collect, analyze and report data on the antimicrobial stewardship program. This also has a D for documentation.

EP 8 requires the hospital to take action on improvement opportunities identified. As always you be careful what you document and how you document your minutes.

So now is the time to start your planning for program design if you don’t already have something started. If this is new for you a logical start point is to identify a planning team to consider what can reasonably be developed at your hospital. Large teaching hospitals are likely to have very sophisticated programs, while smaller community hospitals might have fewer resources, program features and more modest goals. When you have identified the basic skeleton for your program the next step would be to take the proposal to leadership to see what can be authorized for implementation. Consider the advice from TJC in EP 1 at this point for a statement of authorization, budgeting, including references in the IC plan, PI plan, and hospital strategic plan and working with IT to help support the data needs of the program. This is a significantly complex program with only 6 months to launch. If yours was already up and running it will be far easier than if you are starting with a blank sheet of paper.

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