Is your antimicrobial stewardship program ready for a survey?

Experts at IDWeek offered some lessons learned during the first year of The Joint Commission's antimicrobial stewardship standard for acute care.


Nearly all surveyed hospitals avoided citations in the first year of The Joint Commission's antimicrobial stewardship standard for acute care, but there are many more assessments to come.

Photo by Thinkstock
Photo by Thinkstock.

The new standard, which falls under the broader requirement of medication management, applies to more than 4,000 hospitals, as well as about 700 nursing care centers, said David Baker, MD, MPH, FACP, executive vice president for health care quality evaluation at The Joint Commission. Out of 779 hospitals surveyed in 2017, 34 (about 4%) received a citation, he said, “so I think we have been making progress in this country, at least in building a basic foundation.”

Some of those surveyed included three community hospitals within Carolinas HealthCare System in Charlotte, N.C., said Lisa Davidson, MD, an infectious diseases physician at the health system and medical director of its antimicrobial support network. Next year, about 15 visits are scheduled at the system's facilities.

Speaking at IDWeek, Drs. Baker and Davidson offered some lessons learned during the first year of surveys. They grouped their observations by the eight performance elements the Commission assesses.

1. Leaders have established antimicrobial stewardship as an organizational priority.

Most surveyors believe they can accurately assess this element simply by talking with the team and its leaders, said Dr. Baker. “But there are gray areas about whether organizations are putting enough of an effort into this, and that's a continuing challenge,” he said. There are many ways to document organizational leadership, such as through a formal written statement, a strategic plan, dedicated support somewhere in the budget, and job descriptions of program leaders, Dr. Davidson said.

2. The hospital educates relevant clinical staff about antimicrobial resistance and antimicrobial stewardship practices at the time of hire, at the granting of privileges, and periodically thereafter.

This element requires an understanding of what type of educational programs are effective, said Dr. Baker, adding that the best education tends to be one-on-one discussions about an individual case. “We didn't want everybody to just sit in grand rounds, have their coffee and their muffin, check a box, and have something put into their folder to document that,” he said. “That's not going to change care.”

At Carolinas HealthCare System, the team was able to incorporate clinician education into existing processes, Dr. Davidson said. “This is one of those times where you do not need to recreate the wheel, and the hint is to ask your friends in infection prevention. . . . They've gone through this and have been through similar steps and probably have already been required to do clinician education,” she said.

One question that came up during the process was whether to provide the same education for all clinicians. “I think probably for the first go-around, it's a little bit easier to have blanket education that's the same for everybody, and then get into the process of differentiating” based upon clinical discipline or the location of patient care, Dr. Davidson suggested.

She added that multiple nonclinical departments must also be in the loop because accreditation, quality, and credentialing are involved. “Coordinating all this takes a fair amount of time, so you should be prepared that this is probably a six- to 12-month process,” said Dr. Davidson.

3. The hospital educates patients and families about the appropriate use of antimicrobial medications.

On Oct. 1, The Joint Commission deleted this element for hospitals after it proved to be troublesome for many facilities. The requirement will still be in effect for nursing care centers and will be a strong element for ambulatory standards, Dr. Baker said. “But it's a very different issue when you think about hospitalized patients,” he said. “Particularly, is this the most important thing for them to be hearing about? My feeling is no. They need to be understanding their medications, their follow-up appointments, all of these other things.”

The deleted element was still in effect when it came time for Carolinas HealthCare System's surveys earlier this year. Dr. Davidson's group, after eschewing the idea of a patient video, eventually decided to include in patients' admission packets a printed information sheet with five key facts about antibiotic use.

4. The hospital has an antimicrobial stewardship multidisciplinary team.

The requirement specifies that the following members be included when available at a facility: an infectious diseases physician, at least one infection preventionist, at least one pharmacist, and a general practitioner. Dr. Baker said some organizations have asked why The Joint Commission did not include other key personnel, such as nurses, microbiologists, and informaticists. “We don't want to be overly prescriptive,” he said. “We don't want to make this too difficult for some of the smaller hospitals.”

Any hospital that has begun its antimicrobial stewardship program journey should be able to meet this requirement, Dr. Davidson added. “It's really just about providing documentation about who's on the team” through an organizational chart (preferably dated), a membership list of the program subcommittee, and meeting minutes, she said.

5. The hospital's antimicrobial stewardship program includes the CDC's core elements of leadership commitment, accountability, drug expertise, action, tracking, reporting, and education.

The Joint Commission's performance elements are modeled on the CDC's core elements, and many of these requirements are included in other sections. However, more specific components are not, such as protocols, algorithms, and procedures (e.g., treatment algorithms, pharmacy protocols and procedures, reauthorization requirements), Dr. Davidson noted. “[These] represent much of the day-to-day stewardship work and should be highlighted,” she said. Because the antimicrobial stewardship section is new to the surveyors, many were not familiar with the concept in detail, so teams should prepare to spend 15 to 20 minutes discussing stewardship during a survey, Dr. Davidson suggested. “They want you to actually describe your antimicrobial stewardship program journey, which is how you're addressing the CDC core elements,” she said. Surveyors asked to see documentation, Dr. Davidson said, so it was helpful to have a binder available to share (it was also virtually accessible to the team and regularly updated).

6. The hospital's program uses organization-approved protocols.

Examples of protocols and processes that should be documented in this section include clinical pathways, order sets, empiric antibiotic guidelines, and dose-adjustment protocols, Dr. Davidson said. “You can also include . . . whatever it is that you're doing that is at all related in any way to education around antimicrobial stewardship,” she said.

Surveyors specifically asked where clinicians go to find information about pathways and guidelines, Dr. Davidson added. “We did have hospitalists and other people in the room, and they turned to them and said, ‘So where do you find this information?’” she said, adding that, when in doubt about an answer to a question, “The answer can always be, ‘I don't know, but I know how to call my stewardship team, and here's how I contact them for the answer.’” The first page of the aforementioned binder clearly displayed the contact information of the point person for the facility, “and it's bright and it's bold, so everybody knows who that person is,” Dr. Davidson said.

As research determines which protocols are most effective, The Joint Commission is ready to be more prescriptive with this requirement, Dr. Baker noted. “If research emerges on specific protocols that are working, then it's possible we will come in and specifically look for those things,” he said. “Right now, we just want to see if there is a basic structure in place so that you can build on this.”

7. The hospital collects, analyzes, and reports data on its program.

“I know that that can sometimes seem like an overwhelming element to everyone, but you're probably doing something that can be related to reporting,” Dr. Davidson said. “Maybe it's about [Clostridium difficile] rates or maybe it's your antibiogram, because that can count also.”

8. The hospital takes action on improvement opportunities identified in its program.

The final element is all about action and “is probably, in some ways, the trickiest section,” said Dr. Davidson. Here, a hospital should include quality improvement initiatives, for example, efforts to reduce fluoroquinolone use, she said. These should line up with the data reported in the prior section, said Dr. Baker. “The most important thing is we want to see you are acting on the problems that you've identified with data analysis,” he said.