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In our October 2016 newsletter, we covered the new TJC requirements on antimicrobial stewardship.

Now, it’s clear that TJC is incorporating a significant emphasis on this topic into the 2017 survey process for hospitals. The recently released 2017 Survey Activity Guide provides information on how surveyors will weave the topic of antimicrobial stewardship into the different sessions as follows:

Document Review

Four new documents related to antimicrobial stewardship have been added to the Documents List:

  • Documents describing how the hospital is using the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs
  • Hospital-approved antimicrobial stewardship protocols/policies/procedures/order sets
  • Antimicrobial stewardship data
  • Antimicrobial stewardship reports documenting improvement

NOTE: In its initial version of the 2017 SAG, TJC had included two additional documents: a list of patients receiving antimicrobials and documents demonstrating leadership support for the hospital’s antimicrobial stewardship program. On 1/20/17, they removed these two items from the Documents List. They also stated that computer generated lists of patients on antimicrobials are not required but that surveyors will be asking for patients on antimicrobials during the week of the survey.


During tracers, surveyors will pursue the following areas related to antimicrobial stewardship:

  • Education provided to patients on the appropriate use of antibiotics (specifically, to patients who will be discharged on antibiotics)
  • Education provided to staff and LIPs on antimicrobial resistance and the hospital’s antimicrobial stewardship program

Tip: For patient education, make sure you have identified the specific section of the medical record where this patient education should be documented and that you audit for compliance. Also, be aware that for psychiatric hospitals, the only patients to be provided education on antimicrobial medications are inpatients who are discharged on these meds and clinic patients (for clinics surveyed under the Hospital standards) that are being prescribed these meds. It is unlikely that psychiatric hospitals will have any patients in the latter category.

Competence Assessment Session and Medical Staff Credentialing/Privileging Session

During these sessions, the surveyor will inquire about education provided to staff and LIPs on antimicrobial resistance and antimicrobial stewardship.

Tip: TJC has indicated that staff and LIP files will not be reviewed for documentation of this education. Despite that assurance, we recommend that you document this education just as you would any other staff/LIP education.

System Tracers on Data Management and Medication Management

In the Data Management session, surveyors will be looking for data/reports that that demonstrate an improvement in antimicrobial stewardship.

Tip: Since the antimicrobial stewardship requirements just went into effect January 2017, there may not be much data demonstrating improvement for those surveys conducted early in the year. Most psychiatric hospitals, at that point, will be collecting baseline data and setting improvement targets. As the year progresses, the expectations for showing improvement will likely increase. (We clarified this with TJC during a recent conference call.) However, even at the beginning stage of data collection, it would be appropriate for the hospital to set an improvement goal related to staff and patient education.

In both the Data Management and Medication Management sessions, surveyors will discuss the following based on the documents provided in the Document Review Session:

  • How the hospital uses the CDC’s Core Elements of a Hospital Antibiotic Stewardship Program.
  • How the hospital uses antimicrobial stewardship protocols/policies/procedures/order sets
  • The work of the antimicrobial stewardship team

Leadership Session

During this session on the last day, surveyors will probe how hospital leadership has demonstrated that antimicrobial stewardship is an organizational priority.

Tip: Don’t wait until this session on the last day to describe how leadership has made antimicrobial stewardship a priority. Be proactive and include this in your presentation on the first day during the orientation to your organization.

Clearly, the topic of antimicrobial stewardship will play a significant role in the survey process in 2017. With this in mind, the best strategy is to get all these components organized now so you can demonstrate full compliance during your survey!

Also, Joint Commission Resources has made available a free Antimicrobial Stewardship Toolkit to help organizations tackle this initiative. It’s full of background, tools, and tips for how to implement this type of program so check it out!