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Antimicrobial Stewardship – Understanding the Requirements

What are the expectations for an antimicrobial stewardship program?

Any examples are for illustrative purposes only.

The inappropriate use of antimicrobial medications contributes to antibiotic resistance and adverse drug events and improving antimicrobial prescribing practices is a patient safety priority. As a result, The Joint Commission implemented an antimicrobial stewardship standard (MM.09.01.01) for the Hospital (HAP), Critical Access Hospital (CAH), and Nursing Care Center (NCC) accreditation programs on January 1, 2017. 

Organizational Priority and Leadership Commitment
Organization leaders should be prepared to discuss how antimicrobial stewardship has been established as an organizational priority. Documents such as strategic plans, budget plans, and performance improvement plans may be helpful to illustrate the organization’s efforts. Leadership commitment may also be reflected in an accountability document that describes the formal chain of responsibility for the antimicrobial stewardship program.

Although Joint Commission surveyors will not be reviewing staff or medical staff/licensed independent practitioner records on education received regarding antimicrobial resistance and antimicrobial stewardship, they will inquire about the type of education provided by the organization. During patient tracers, surveyors may ask staff and licensed independent practitioners about the education they have received. Organizations may consider providing written material such as the organization’s antibiogram (if available) to demonstrate compliance.

Antimicrobial Stewardship Multidisciplinary Team
The Joint Commission is aware that the composition of the multidisciplinary team may vary based on the type of organization being surveyed, as well as the geographic location of the organization. This is the reason MM.09.01.01, EP 4 indicates that the four practitioners listed should be on the multidisciplinary team “when available in the setting.” However, it would not be acceptable for an organization to have a team consisting of only a pharmacist and a nurse when physicians and other licensed independent practitioners are available in the organization (e.g., an infectious disease consultation team exists).

Antimicrobial Stewardship Program Components
The organization needs to have a document indicating how each of the core elements listed MM.09.01.01, EP 5 is addressed in its antimicrobial stewardship program. This information can be located in a separate document or can be included in other antimicrobial stewardship documents. Documentation does not have to be provided in a lengthy format but needs to describe how the core elements are addressed in the antimicrobial stewardship program.

A list of multidisciplinary protocols is provided for organizations to consider based on the care, treatment, and services delivered; they are not requirements.

Data Collection and Analysis
The Joint Commission does not specify the type of antimicrobial stewardship data that organizations should collect. It is the organization’s responsibility to identify which antimicrobial stewardship data it will collect, analyze, and report. Organizations are encouraged to review the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs at and The Core Elements of Antibiotic Stewardship for Nursing Homes at for examples of measures that can be used to collect antimicrobial stewardship data.

Additionally, the National Quality Partners Playbook on Antibiotic Stewardship in Acute Care provides examples of basic, intermediate, and advanced measures. (

Improvement Opportunities
Organizations need to use the antimicrobial stewardship data they have collected and analyzed to identify improvement opportunities for their antimicrobial stewardship program. If the data demonstrate that antimicrobial stewardship improvements are not necessary, the organization should share the data with the surveyor. If improvements are identified, the organization should be prepared to discuss the actions taken to improve the program. 

Last updated on March 17, 2021
Manual: Critical Access Hospital
Chapter: Medication Management MM

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