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New Antimicrobial Stewardship Standard Issued by Joint Commission

Cheryl Thompson

Cheryl A. ThompsonDirector
News Center

The Joint Commission on June 22 issued a prepublication version of the new antimicrobial stewardship standard for hospitals, critical access hospitals, and nursing care centers and stated that it becomes effective January 1.

This new medication management standard has eight so-called elements of performance. One of these requires accredited healthcare organizations to have an "antimicrobial stewardship multidisciplinary team" and, when available in the healthcare setting, at least one pharmacist on that team.

Margaret VanAmringe, executive vice president for Joint Commission's public policy and government relations, said the new standard was created to ensure that healthcare organizations have an identifiable antimicrobial stewardship program.

She said the Joint Commission already has 15 standards that "relate to" a healthcare organization's antimicrobial stewardship program.

"But that doesn't mean you have identified accountability, resources, the right competencies for stewardship," VanAmringe said. "That's different."

In addition to having a multidisciplinary antimicrobial stewardship team with certain professionals as members, the new standard requires accredited organizations to

  • Show leadership's commitment to the antimicrobial stewardship program,
  • Educate staff members and licensed independent practitioners,
  • Educate patients,
  • Ensure the program includes the Centers for Disease Control and Prevention's seven core elements of antimicrobial stewardship programs in hospitals or nursing homes,
  • Use organization-approved multidisciplinary protocols in the program,
  • Collect, analyze, and report data on the program, and
  • Act on the opportunities for improvement identified through the program.

The standard, said Bona Benjamin, ASHP director of medication-use quality improvement, reinforces ASHP's position that pharmacists have an important role in antimicrobial stewardship.

Resources on antimicrobial stewardship are available at ASHP's website. This online resource center was recently cited by the Centers for Medicare and Medicaid Services (CMS) as a source of guidance on best practices for implementing antimicrobial stewardship programs.

Soon to be added to the resource center, said Deborah Pasko, ASHP director of medication safety and quality, is the Antibiotic Stewardship in Acute Care: A Practical Playbook, by the National Quality Forum's National Quality Partners Antibiotic Stewardship Action Team.

Also, ASHP members are preparing webinars on antimicrobial stewardship, she said, and recordings of those webinars will be added to the resource center.

VanAmringesaid the Joint Commission discussed its plan for an antimicrobial stewardship standard with CMS to ensure that the accrediting organization headed down a road compatible with the agency's plan.

The agency, by virtue of a September 2014 presidential executive order to the Department of Health and Human Services, was known to be working on new regulations that would require inpatient healthcare facilities "to implement robust antibiotic stewardship programs that adhere to best practices."

In mid-June, CMS proposed the new regulatory standard "Antibiotic Stewardship Program Organization and Policies" as part of the infection-control condition of participation for hospitals and critical access hospitals in the Medicare and Medicaid programs. The proposal is one of several the agency made in its June 16 proposed rule. Comments on all parts of the proposed rule are due to CMS by August 15.

VanAmringe said Joint Commission's new standard has "so much commonality" with CMS's proposed standard that she is "not particularly worried" about the agency's upcoming assessment of whether the accrediting organization's standard meets the government's need.

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