On Infection Prevention & Control

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New Ambulatory Requirement Emphasizes Formalizing Organizational Antimicrobial Stewardship Goals


By Christina Cordero, PhD, MPH, project director, Department of Standards and Survey Methods 
Effective January 1, 2020, new antimicrobial stewardship requirements will be applicable to Joint Commission-accredited ambulatory health care organizations that routinely prescribe antimicrobial medications, including organizations providing:
  • medical or dental services
  • episodic care
  • occupational/worksite health
  •  urgent/immediate care
  • convenient care. 

The requirements are not applicable to ambulatory surgery centers or the office-based surgery program.

The inappropriate use of antimicrobial medications contributes to antibiotic resistance and adverse drug events. Improving antimicrobial prescribing practices is a patient safety priority. As a result, The Joint Commission has developed a new standard in the Medication Management (MM) chapter (Standard MM.09.01.03) with five new elements of performance (EPs) addressing antimicrobial stewardship in the ambulatory setting.

The new EPs address the following concepts: 

  • identifying an antimicrobial stewardship leader
  • establishing an annual antimicrobial stewardship goal
  • implementing evidence-based practice guidelines related to the goal
  • providing clinical staff with educational resources related to the goal
  • collecting, analyzing and reporting data related to the antimicrobial stewardship goal
Prioritizing at the Organizational Level
Standard MM.09.01.03 reads: Antimicrobial stewardship is identified as an organizational priority.
Its related EP 1 requires organizations to identify an individual(s) responsible for developing, implementing and monitoring activities to promote appropriate antimicrobial medication prescribing practices. 
A “champion” who is accountable for an organization’s antimicrobial stewardship activities increases the likelihood of success by establishing clear lines of accountability. Identifying an individual(s) for this role also demonstrates an organizational commitment to improving the use of antimicrobial medications. Antimicrobial stewardship activities may be the individual’s primary job responsibility or may be in addition to other duties.
Evidence-Based Annual Goals
EP 2 asks organizations to set at least one annual antimicrobial stewardship goal. Examples of antimicrobial stewardship goals include decreasing the use of antibiotics to treat viral infections or addressing overuse of a specific medication. 
This allows the organization to focus its efforts on a specific opportunity to improve antimicrobial prescribing practices. In developing this goal, organizations may consider reviewing their prescribing practices or consulting available national data to identify areas of inappropriate antimicrobial medication use. 
Per EP 3, organizations should use evidence-based practice guidelines related to their annual antimicrobial stewardship goal(s). 
Guidelines may include appropriate diagnostic criteria and treatment recommendations to use when prescribing antimicrobial medications. Protocols and guidelines help ensure that patients who need antibiotics receive them while those without an indication do not. 
Educating Staff on Appropriate Prescribing Practices
Requirements of EP4 state the organization must provide all clinical staff and licensed independent practitioners with educational resources related to its antimicrobial stewardship goal(s) and strategies that promote appropriate antimicrobial medication prescribing practices. 
This is done so patients receive clear, consistent recommendations when antimicrobials are not indicated. Educational resources may include recommended:
  • prescribing practices 
  • medication selection
  • dosing
  • duration
An important component of this education includes explaining why some patients may not need an antibiotic, and may require addressing patient expectations and discussing possible adverse effects of antibiotics. 
Data Collection
Per EP 5, the organization must collect, analyze, and report data pertaining to the antimicrobial stewardship goal(s) to organizational leadership and prescribers. 
Depending on the goal selected, data may include:
  • antimicrobial medication prescribing patterns
  • antimicrobial resistance patterns
  • evaluation of the antimicrobial stewardship activities implemented
It is important to evaluate whether an organization’s antimicrobial stewardship activities are successful and to share with leadership any progress toward achieving the antimicrobial stewardship goal. Organizations may incorporate electronic or manual data collection and analysis methods to identify improvements. However, a sustained effort is often required before organizations see change in the culture of antimicrobial prescribing. 
The prepublication version of the antimicrobial stewardship requirements will be available online until the end of December 2019.
Christina Cordero, PhD, is a Project Director in the Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation at The Joint Commission. Dr. Cordero is focused on standards development projects for the hospital and laboratory accreditation programs. She developed the patient-centered communication standards and The Joint Commission monograph Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.  Dr. Cordero has also provided research and technical support to The Joint Commission’s Hospitals, Language, and Culture: A Snapshot of the Nation study, and she is a contributing author of One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations. Prior to joining The Joint Commission, Dr. Cordero conducted basic science and public health research at Northwestern University’s Feinberg School of Medicine.