Approved: New Antimicrobial Stewardship Standard

The Joint Commission recently announced a new Medication Management (MM)
standard for hospitals, critical access hospitals, and nursing care centers. Stan￾dard MM.09.01.01 addresses antimicrobial stewardship and becomes effective
January 1, 2017.
Current scientific literature emphasizes the need to reduce the use of inap￾propriate antimicrobials in all health care settings due to antimicrobial resistance.
According to the World Health Organization (WHO): “Antimicrobial resistance
threatens the effective prevention and treatment of an ever-increasing range of
infections caused by bacteria, parasites, viruses and fungi.”1
The Centers for Disease
Control and Prevention (CDC) identified that 20%–50% of all antibiotics pre￾scribed in US acute care hospitals are either unnecessary or inappropriate.2
The
CDC has also stated: “Antibiotics are among the most commonly prescribed medi￾cations in nursing homes. Up to 70% of long-term care facilities’ residents receive
an antibiotic every year.”3
On June 2, 2015, The Joint Commission participated in the White House
Forum on Antibiotic Stewardship. The Joint Commission joined representatives
from more than 150 major health care organizations, food companies, retailers, and
animal health organizations at the forum to express commitment for implementing
changes over the next five years to slow the emergence of antibiotic-resistant bacte￾ria, detect resistant strains, preserve the efficacy of existing antibiotics, and prevent
the spread of resistant infections.4
Subsequently, The Joint Commission developed the antimicrobial steward￾ship standard for hospitals, critical access
hospitals, nursing care centers, ambula￾tory care organizations, and office-based
surgery practices and conducted a field
review in November and December
2015. Prior to and during the field
review, Joint Commission staff conducted
stakeholder calls on the proposed antimi￾crobial stewardship standard with several
governmental and professional organiza￾tions, including the Centers for Medicare & Medicaid Services (CMS), the CDC, and the Society for
Healthcare Epidemiology of America (SHEA).
There was significant support for the antimicrobial
stewardship standard for the hospital, critical access hospital,
and nursing care center accreditation programs. Additionally,
CMS is in the process of developing a Condition(s) of Par￾ticipation (CoP) on antimicrobial stewardship for the hospital
and nursing home settings, which therefore aligns the Joint
Commission’s standard with CMS’s plans for a CoP(s) in this
area. In the meantime, the antimicrobial stewardship standard
for Joint Commission–accredited ambulatory care organiza￾tions and office-based surgery practices is still in development.
The approved antimicrobial stewardship standard and
EPs are shown in the box that begins below and will also be
displayed on The Joint Commission website at http://www.
jointcommission.org/standards_information/prepublication_
standards.aspx. In addition, the requirements will be posted
in the fall 2016 E-dition® update and published in the 2017
Comprehensive Accreditation Manual for the Critical Access
Hospital, Hospital, and Nursing Care Center Accreditation
Programs.
Questions regarding the new antimicrobial stewardship
standard may be directed to Kelly Podgorny, DNP, CPHQ, RN,
project director, Department of Standards and Survey Methods,
The Joint Commission, at kpodgorny@jointcommission.org. P
References
1. World Health Organization. Antimicrobial Resistance. (Updated: Apr
2015.) Accessed May 27, 2016. http://www.who.int/mediacentre/
factsheets/fs194/en/#
2. Centers for Disease Control and Prevention. Core Elements of Hospital
Antibiotic Stewardship Programs. Accessed May 27, 2016. http://www.
cdc.gov/getsmart/healthcare/implementation/core-elements.html
3. Centers for Disease Control and Prevention. Antibiotic Use in Nursing
Homes. Nov 5, 2013. Accessed May 27, 2016. http://www.cdc.gov/
getsmart/healthcare/learn-from-others/factsheets/nursing-homes.html
4. The Joint Commission. Joint Commission Joins White House Effort to
Reduce Antibiotic Overuse. Jt Comm Perspect. 2015 Jul;35(7):4, 11.

Standard MM.09.01.01
The [critical access] hospital has an antimicrobial stewardship
program based on current scientific literature.
Elements of Performance for MM.09.01.01
1. Leaders establish antimicrobial stewardship as an orga￾nizational priority. (See also LD.01.03.01, EP 5)
Note: Examples of leadership commitment to an antimi￾crobial stewardship program are as follows:
l Accountability documents
l Budget plans
l Infection prevention plans
l Performance improvement plans
l Strategic plans
l Using the electronic health record to collect antimi￾crobial stewardship data
2. The [critical access] hospital educates staff and li￾censed independent practitioners involved in antimicro￾bial ordering, dispensing, administration, and monitor￾ing about antimicrobial resistance and antimicrobial
stewardship practices. Education occurs upon hire or
granting of initial privileges and periodically thereafter,
based on organizational need.
3. The [critical access] hospital educates patients, and
their families as needed, regarding the appropriate use
of antimicrobial medications, including antibiotics. (For
more information on patient education, refer to Stan dard PC.02.03.01)
Note: An example of an educational tool that can be
used for patients and families includes the Centers for
Disease Control and Prevention’s Get Smart docu￾ment, “Viruses or Bacteria—What’s got you sick? at
http://www.cdc.gov/getsmart/community/downloads/
getsmart-chart.pdf.
4. The [critical access] hospital has an antimicrobial stew￾ardship multidisciplinary team that includes the follow￾ing members, when available in the setting:
l Infectious disease physician
l Infection preventionist(s)
l Pharmacist(s)
l Practitioner
Note 1: Part-time or consultant staff are acceptable as
members of the antimicrobial stewardship multidisci￾plinary team.
Note 2: Telehealth staff are acceptable as members of
the antimicrobial stewardship multidisciplinary team.
5. D The [critical access] hospital’s antimicrobial steward￾ship program includes the following core elements:
l Leadership commitment: Dedicating necessary hu￾man, financial, and information technology resources.
l Accountability: Appointing a single leader respon￾sible for program outcomes. Experience with suc￾cessful programs shows that a physician leader is
effective.
l Drug expertise: Appointing a single pharmacist leader
responsible for working to improve antibiotic use.
l Action: Implementing recommended actions, such
as systemic evaluation of ongoing treatment need,
after a set period of initial treatment (for example,
“antibiotic time out” after 48 hours).
l Tracking: Monitoring the antimicrobial stewardship
program, which may include information on antibi￾otic prescribing and resistance patterns.
l Reporting: Regularly reporting information on the
antimicrobial stewardship program, which may
include information on antibiotic use and resistance,
to doctors, nurses, and relevant staff.
l Education: Educating practitioners, staff, and
patients on the antimicrobial program, which may
include information about resistance and optimal
prescribing. (See also IC.02.01.01, EP 1 and
NPSG.07.03.01, EP 5)
Note: These core elements were cited from the Centers
for Disease Control and Prevention’s Core Elements of
Hospital Antibiotic Stewardship Programs (http://www.
cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf).
The Joint Commission recommends that organizations
use this document when designing their antimicrobial
stewardship program.
6. D The [critical access] hospital’s antimicrobial steward￾ship program uses organization-approved multidisci￾plinary protocols (for example, policies and procedures).
Note: Examples of protocols are as follows:
l Antibiotic Formulary Restrictions
l Assessment of Appropriateness of Antibiotics for
Community-Acquired Pneumonia
l Assessment of Appropriateness of Antibiotics for
Skin and Soft Tissue Infections
l Assessment of Appropriateness of Antibiotics for
Urinary Tract Infections
l Care of the Patient with Clostridium difficile (c.-diff)
l Guidelines for Antimicrobial Use in Adults
l Guidelines for Antimicrobial Use in Pediatrics
l Plan for Parenteral to Oral Antibiotic Conversion
l Preauthorization Requirements for Specific
Antimicrobials
l Use of Prophylactic Antibiotics
7. D The [critical access] hospital collects, analyzes, and
reports data on its antimicrobial stewardship program.
Note: Examples of topics to collect and analyze data
on may include evaluation of the antimicrobial steward￾ship program, antimicrobial prescribing patterns, and
antimicrobial resistance patterns.
8. D The [critical access] hospital takes action on im￾provement opportunities identified in its antimicrobial
stewardship program. (See also MM.08.01.01, EP 6)

Applicable to Nursing Care Centers
Effective January 1, 2017
Medication Management (MM)
Standard MM.09.01.01
The organization has an antimicrobial stewardship program
based on current scientific literature.
Elements of Performance for MM.09.01.01
1. Leaders establish antimicrobial stewardship as an orga￾nizational priority. (See also LD.01.03.01, EP 5)
Note: Examples of leadership commitment to an antimi￾crobial stewardship program are as follows:
l Accountability documents
l Budget plans
l Infection prevention plans
l Performance improvement plans
l Strategic plans
l Using the electronic health record to collect antimi￾crobial stewardship data
2. The organization educates staff and licensed inde￾pendent practitioners involved in antimicrobial order￾ing, dispensing, administration, and monitoring about
antimicrobial resistance and antimicrobial stewardship
practices. Education occurs upon hire or granting of
initial privileges and periodically thereafter, based on
organizational need.
3. The organization educates residents, and their families
as needed, regarding the appropriate use of antimi￾crobial medications, including antibiotics. (For more
information on patient and resident education, refer to
Standard PC.02.03.01)
Note: An example of an educational tool that can be
used for patients and families includes the Centers for
Disease Control and Prevention’s Get Smart docu￾ment, “Viruses or Bacteria—What’s got you sick? at
http://www.cdc.gov/getsmart/community/downloads/
getsmart-chart.pdf.
4. The organization has an antimicrobial stewardship mul￾tidisciplinary team that includes the following members,
when available in the setting:
l Infectious disease physician
l Infection preventionist(s)
l Pharmacist(s)
l Practitioner
Note 1: Part-time or consultant staff are acceptable as
members of the antimicrobial stewardship multidisci￾plinary team.
Note 2: Telehealth staff are acceptable as members of
the antimicrobial stewardship multidisciplinary team.
5. D The organization’s antimicrobial stewardship pro￾gram includes the following core elements:
l Leadership commitment: Demonstrate support and
commitment to safe and appropriate antibiotic use
in your facility.
l Accountability: Identify physician, nursing, and phar￾macy leads responsible for promoting and oversee￾ing antibiotic stewardship activities in your facility.
l Drug expertise: Establish access to consultant
pharmacists or other individuals with experience or
training in antibiotic stewardship for your facility.
l Action: Implement policy or practice changes to
improve antibiotic use.
l Tracking: Monitor and measure the use of antibiotic
use and at least one outcome from antibiotic use in
your facility.
l Reporting: Regularly reporting information on the
antimicrobial stewardship program, which may
include antibiotic use and resistance, to physicians
and other practitioners, nurses, and relevant staff.
l Education: Provide resources to physicians and
other practitioners, nursing staff, residents, and
families about antibiotic resistance and opportunities
for improving antibiotic use. (See also IC.02.01.01,
EP 1)
Note: These core elements were cited from the Centers
for Disease Control and Prevention’s The Core Ele￾ments of Antibiotic Stewardship for Nursing Homes
(http://www.cdc.gov/longtermcare/prevention/antibiotic￾stewardship.html). The Joint Commission recommends
that nursing care centers use this document when
designing their antimicrobial stewardship program.
6. D The organization’s antimicrobial stewardship pro￾gram uses organization-approved multidisciplinary
protocols (for example, policies and procedures).
Note: Examples of protocols are as follows:
l Antibiotic Formulary Restrictions
l Assessment of Appropriateness of Antibiotics for
Community-Acquired Pneumonia
l Assessment of Appropriateness of Antibiotics for
Skin and Soft Tissue Infections
l Care of the Long Term Care Patient with a Urinary
Tract Infection
l Care of the Patient with Clostridium difficile (c.-diff)
l Facility Guidelines for Antimicrobial Use in Adults
l Plan for Parenteral to Oral Antibiotic Conversion
l Preauthorization Requirements for Specific
Antimicrobials
7. D The organization collects, analyzes, and reports data
on its antimicrobial stewardship program.
Note: Examples of topics to collect and analyze data
on may include evaluation of the antimicrobial steward￾ship program, antimicrobial prescribing patterns, and
antimicrobial resistance patterns.
8. D The organization takes action on improvement op￾portunities identified in its antimicrobial stewardship
program. (See also MM.08.01.01, EP 6)