Preparing for The Joint Commission Standard on Antimicrobial Stewardship: Practical Tips for Survey Success

BACKGROUND: Effective January 1, 2017, Standard MM.09.01.01 addressing antimicrobial stewardship is enforceable by The Joint Commission (TJC). In order to ensure TJC survey success, we implemented a systematic approach to address each associated Element of Performance. METHODS: Upon notification of TJC Pre-Publication Standard MM.09.01.01 in 2016, we held an Antimicrobial Stewardship Program (ASP) team Transformational Summit, at which time we developed a strategic plan including goals and programs aimed at optimizing our existing program and satisfying TJC ASP Standard. Members of our ASP include Infectious Diseases pharmacists and physicians, pharmacy administration, the microbiology laboratory directors, infection preventionists, and a data manager. RESULTS: Specific programs developed to meet each Element of Performance included: (EP1) composing a strategic plan based on TJC ASP standard and an ASP letter of support for senior leadership to endorse; (EP2) developing an educational program for providers including a required eLearning module and work station screensavers regarding antimicrobial resistance and stewardship principles; (EP3) creating educational materials for patients to view during their inpatient stay via our online portal and creating patient-directed screensavers for the in- and outpatient settings; (EP4) expanding our ASP team to include additional members; (EP5) implementing a hospital-wide antibiotic time-out program and a plan for providing drug use feedback to front-line providers; (EP6) updating guidelines for the management of pneumonia and MRSA bacteremia and developing a systematic approach for prospective audit and feedback of restricted antimicrobials; (EP7) constructing a dashboard for tracking antimicrobial use and cost trends; (EP8) creating an ASP intervention worklist in our electronic health record identifying patients with positive blood cultures and those on high-risk antimicrobials. CONCLUSION: As a result of TJC Standard MM.09.01.01 regarding antimicrobial stewardship, a systematic approach to addressing each Element of Performance was developed. Sharing the details of our approach may benefit other institutions as they prepare the TJC survey. DISCLOSURES: All authors: No reported disclosures.