Medication Management (MM) (Nursing Care Center / Nursing Care Center)
Antimicrobial Stewardship – Multidisciplinary Team Requirements - Standard MM.09.01.01, EP 4
Modify | January 13, 2017
If an organization does not have an infectious disease physician on the antimicrobial stewardship multidisciplinary team will it receive a Requirement for Improvement (RFI)?
This depends on the availability of infectious disease physicians to serve in this capacity. The Joint Commission is aware that the composition of this 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).
Note: Some organizations such as critical access hospitals and nursing care centers may not have the Medication Management System Tracer. In these cases, antimicrobial stewardship will be evaluated during other scheduled activities, such as Orientation to the Organization, Data Use System Tracer, and Individual Patient Tracers.
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