Safety First Blog

Up Close: Joint Commission Requirements for Antimicrobial Stewardship Programs

Posted by Laura Paxton on Jun 2, 2022 12:37:33 PM
Laura Paxton
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We’re continuing to expand on the content from our most popular blog in 2021 - “From Our Customers: The Top 8 Questions To Expect In Joint Commission Inspections.” This time we’ll explain antimicrobial stewardship and how to prepare for the Joint Commission inspectors.  

Since 2017, the Joint Commission has required accredited critical access hospitals, hospitals, and nursing care centers to comply with Medication Management (MM) standard, MM.09.01.01, on antimicrobial stewardship with the goal to enlist healthcare providers in the prevention of antibiotic resistance.

Often “antimicrobial stewardship” and “antibiotic stewardship” are used interchangeably, however, antibiotics are a subset of an overarching antimicrobial stewardship program. A broad program includes microbials such as antivirals, antiprotozoals, antifungals AND antibiotics. According to the Joint Commission, a healthcare provider is required to develop and maintain a stewardship program that includes interventions to reduce unnecessary or incorrect antibiotic use and ultimately prevent bacterial resistance. In this article, we’ll focus on antibiotics. 

Why a formal program? 

The Centers for Disease Control & Prevention (CDC) began reporting on illnesses and death caused by antimicrobial resistance in the 2013 AR Threat Report, which at the time reported that at least 2 million illnesses and 23,000 deaths are caused by antibiotic-resistant bacteria in the United States. In 2019, the AR Threat Report stated the numbers were growing with more than 2.8 million antibiotic-resistant infections and 35,000 deaths in the U.S. per year. 

This growing danger led to the creation of the Joint Commission standard enforced today to help preserve drug effectiveness. The Mayo Clinic says an effective antimicrobial stewardship program will: 

  • Maintain the effectiveness of current antibiotics
  • Extend the lifespan of current antibiotics
  • Protect patients from antibiotic-resistant infections
  • Prevent side effects from incorrect antibiotic use 

What causes antimicrobial resistance? 

Bacterial drug resistance is normal and expected but the way in which the drugs are used can affect the speed and the extent of resistance. 

Common causes of antibiotic resistance are unnecessary prescriptions (for viral infections or non-bacterial illness) and the use of a broad-spectrum antibiotic when a narrow-spectrum, first-line antibiotic could be just as effective. 

According to the CDC, 80% - 90% of antibiotics are prescribed in outpatient settings such as general practitioners or clinics. Of those antibiotic prescriptions, 30% are unnecessary. 

Key Strategies for Antimicrobial Resistance Prevention

Depending on where you look, you’ll find a variety of recommended best practices for an antimicrobial stewardship program. The basic components include: 

  1. Use of hospital-based antimicrobial data to determine the correct treatment (whether an antibiotic is actually the best treatment).
  2. Avoid unnecessary use of broad-spectrum antibiotics
  3. Shorten treatment duration when possible.
  4. In order to determine best treatment evaluate pharmacokinetic and pharmacodynamic factors. 

What the Joint Commission is Looking for: 

  1. The organization and leadership must demonstrate that antimicrobial stewardship is a priority through strategic plans, budget plans, and performance improvement plans. Also key is documentation of the formal chain of accountability for the antimicrobial stewardship program. 
  2. Education around antimicrobial resistance and stewardship is important to the Joint Commission, however, they do not outline specific education requirements or documentation needed. Inspectors may ask hospital staff during patient tracers to discuss any antimicrobial training they’ve received. 
  3. A multidisciplinary antimicrobial team of at least four of the following staff - infectious disease physician, infection preventionist, pharmacist, practitioner - is required, though the Joint Commission is flexible depending on the hospital’s size and geographic location. 
  4. While no specific format is required, the Joint Commission does ask for at least high-level documentation of an organization’s antimicrobial stewardship program illustrating the adherence with these core components detailed in MM.09.01.01, EP 5. These include: 
    1. Leadership 
    2. Accountability
    3. Drug expertise
    4. Action 
    5. Tracking
    6. Reporting 
    7. Education
  5. The Joint Commission requires hospitals to collect and analyze data on their antimicrobial stewardship program.
  6. Once the data is collected, analyzed and reported on, it must be used to analyze areas for improvement. 

As with many accreditation associations, the Joint Commission gives a broad outline of requirements with the understanding that each healthcare facility is unique. While this is helpful, it can also leave many organizations wondering if they’ve done enough to prepare in terms of documentation, training and communication. The Rpharmy team is comprised of former pharmacy techs and directors who have been in your shoes and are eager to help you meet compliance. We also speak to healthcare organizations across the country and are happy to answer questions regarding USP <800> compliance or any other regulation or guideline you need help with. 

Stay tuned because soon we’ll be updating the list based on what our clients have recently experienced in Joint Commission inspections. In the meantime, check out USP <797>: Are you ready? to ensure you’re doing all you can to protect healthcare workers from microbial contamination.  

Topics: Policy, Formweb, Formulary

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