in AHC, CAH, HAP, NCC, and OBS Standard MM.09.01.01 1 2 3 4 AHC CAH The organization has an antimicrobial stewardship program based on evidence-based national guidelines. The critical access hospital has an antimicrobial stewardship program based on evidence-based national guidelines. 5 HAP The hospital has an antimicrobial stewardship program based on evidence-based national guidelines. 6 7 NCC The organization has an antimicrobial stewardship program based on evidence-based national guidelines. 8 OBS The practice has an antimicrobial stewardship program based on evidence-based national guidelines. Elements of Performance for MM.09.01.01 EP Text for MM.09.01.01, EP 1 9 10 11 12 13 14 15 16 AHC 1. CAH 1. HAP 1. NCC 1. 17 OBS 1. Leaders establish antimicrobial stewardship as an organizational priority. EP Text for MM.09.01.01, EP 2 18 19 20 21 22 23 24 25 26 27 28 29 AHC 2. CAH 2. HAP 2. NCC 2. Page 1 of 6
30 31 32 OBS 2. EP Text for MM.09.01.01, EP 3 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 AHC 3. CAH 3. HAP 3. NCC 3. OBS 3. Educate residents, and their families as needed, regarding the appropriate use of antimicrobial EP Text for MM.09.01.01, EP 4 58 59 60 61 62 63 64 65 66 67 68 69 70 71 AHC 4. CAH 4. The organization has an antimicrobial stewardship multidisciplinary team that includes the following The critical access hospital has an antimicrobial stewardship multidisciplinary team that includes the following Page 2 of 6
72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 HAP 4. NCC 4. OBS 4. The hospital has an antimicrobial stewardship multidisciplinary team that includes the following The organization has an antimicrobial stewardship multidisciplinary team that includes the following The practice has an antimicrobial stewardship multidisciplinary team that includes the following EP Text for MM.09.01.01, EP 5 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 AHC 5. CAH 5. The organization s antimicrobial stewardship program includes the following core elements: (See also IC.02.01.01, EP 1) The critical access hospital's antimicrobial stewardship program includes the following core elements: (See also IC.02.01.01, EP 1 and NPSG.07.03.01, EP Page 3 of 6
121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 HAP 5. NCC 5. OBS 5. The hospital's antimicrobial stewardship program includes the following core elements: (See also IC.02.01.01, EP 1 and NPSG.07.03.01, EP The organization s antimicrobial stewardship program includes the following core elements: (See also IC.02.01.01, EP 1) Note: These core elements were cited from the Centers for Disease Control and Prevention s The Core Elements of Antibiotic Stewardship for Nursing Homes (http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html). The Joint Commission recommends that nursing care centers use this document when designing their antimicrobial stewardship The practice's antimicrobial stewardship program includes the following core elements: (See also IC.02.01.01, EP 1) Page 4 of 6
EP Text for MM.09.01.01, EP 6 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 AHC 6. CAH 6. HAP 6. NCC 6. OBS 6. The organization s antimicrobial stewardship program uses organization-approved multidisciplinary - Guidelines for Antimicrobial Use in Adults - Guidelines for Antimicrobial Use in Pediatrics - Treatment Guidelines for Common Infections - "Wait-and-See" Antibiotic Protocol The critical access hospital's antimicrobial stewardship program uses organization-approved multidisciplinary - Guidelines for Antimicrobial Use in Adults - Guidelines for Antimicrobial Use in Pediatrics The hospital's antimicrobial stewardship program uses organization-approved multidisciplinary - Guidelines for Antimicrobial Use in Adults - Guidelines for Antimicrobial Use in Pediatrics The organization s antimicrobial stewardship program uses organization-approved multidisciplinary - Facility Guidelines for Antimicrobial Use in Adults - Care of the Long Term Care Patient with a Urinary Tract Infection The practice's antimicrobial stewardship program uses organization-approved multidisciplinary - Use of Prophylactic Antibiotics EP Text for MM.09.01.01, EP 7 208 209 AHC 7. The organization collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns. (See also MM.08.01.01, EPs 1 and 2) Page 5 of 6
210 211 212 213 214 215 216 217 CAH 7. HAP 7. NCC 7. OBS 7. The critical access hospital collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns. (See also MM.08.01.01, EPs 1 and 2) The hospital collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns. (See also MM.08.01.01, EPs 1 and 2) The organization collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns. (See also MM.08.01.01, EPs 1 and 2) The practice collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns. (See also MM.08.01.01, EP 1) EP Text for MM.09.01.01, EP 8 218 219 220 221 222 223 224 225 226 227 AHC 8. CAH 8. HAP 8. NCC 8. OBS 8. The organization takes action on improvement opportunities identified in its antimicrobial stewardship (See also MM.08.01.01, EP 6) The critical access hospital takes action on improvement opportunities identified in its antimicrobial stewardship (See also MM.08.01.01, EP 6) The hospital takes action on improvement opportunities identified in its antimicrobial stewardship (See also MM.08.01.01, EP 6) The organization takes action on improvement opportunities identified in its antimicrobial stewardship (See also MM.08.01.01, EP 6) The practice takes action on improvement opportunities identified in its antimicrobial stewardship (See also MM.08.01.01, EP 6) Page 6 of 6