Pediatric ASP Toolkit

Joint Commission

Antibiotic Stewardship Standard (Effective January 1, 2017)

For critical access hospitals, the Joint Commission standard requires that the [critical access] hospital has an Antibiotic stewardship program “based on current scientific literature”. (Standard MM.09.01.01)

8 Elements of Performance include:

  1. Leadership commitment
  2. Education to staff and licensed independent practitioners involved in antibiotic ordering, dispensing, administration, and monitoring about antibiotic resistance and antibiotic stewardship
  3. Education to patients and their families regarding the appropriate use of antibiotics
  4. Antibiotic stewardship team to include (when available): (1) Infectious disease physician, infection preventionist(s), Pharmacist(s), Practitioners
  5. The antibiotic stewardship program includes the 7 core elements outlined by the CDC
  6. The ASP uses organization-approved multidisciplinary protocols
  7. The hospital collects, analyzes, and reports data on its antibiotic stewardship program
  8. The hospital takes action on improvement opportunities identified in its antibiotic stewardship

The Joint Commission also introduced standards for antibiotic stewardship programs in nursing care centers.

Ambulatory antimicrobial stewardship standard (Effective January 1, 2020)

Requirements will be applicable to Joint Commission-accredited ambulatory health care organizations that routinely prescribe antimicrobial medications.

5 Elements of Performance include:

  1. Identifying an antimicrobial stewardship leader.
  2. Establishing an annual antimicrobial stewardship goal.
  3. Implementing evidence-based practice guidelines related to the antimicrobial stewardship goal.
  4. Providing clinical staff with educational resources related to the antimicrobial stewardship goal.
  5. Collecting, analyzing, and reporting data related to the antimicrobial stewardship goal.

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