Pharmacy OneSource Blog

Joint Commission Proposes Standard to Improve Antimicrobial Stewardship Program

Posted on 12/17/15


In June 2015, the White House brought together over 150 health and animal stakeholders involved in antibiotic stewardship to develop, promote, and implement programs to ensure responsible use of antibiotics.1 The Joint Commission (TJC) is a committed part of this program to reduce antibiotic overuse and recently proposed a new standard on antimicrobial resistance. Comments on this proposed standard are due by December 30, 2015, and can be submitted via an online survey, online form, or by mail.2

This proposed standard affects more than the Hospital Accreditation Program (HAP) since it also applies to Ambulatory Health Care, Critical Access Hospitals, Nursing Care Centers, and Office Based Surgery. The proposed standard MM.01.01.09 (Medical Management) states that all of these organizations and facilities have an antimicrobial stewardship program based on evidence-based national guidelines.

There are eight Elements of Performance (EP):

  1. Leaders establish antimicrobial stewardship as an organizational priority.

  2. Educate staff and licensed independent practitioners involved in antimicrobial ordering, dispensing, administration, and monitoring about antimicrobial resistance and antimicrobial stewardship practices. Education occurs upon hire and annually thereafter.

  3. Educate patients, and their families as needed, regarding the appropriate use of antimicrobial medications, including antibiotics.

  4. The organization has an antimicrobial stewardship multidisciplinary team that includes the following members, when available in the setting:

  • Pharmacist(s)
  • Infectious diseases physician
  • Infection preventionist(s)
  • Clinical microbiologist 
  1. The organization’s antimicrobial stewardship program includes the following core elements:

  • Leadership commitment
  • Accountability
  • Drug expertise
  • Action
  • Tracking
  • Reporting
  • Education 
  1. The organization’s antimicrobial stewardship program uses organization-approved multidisciplinary protocols.

  2. The organization collects and analyzes data on its antimicrobial stewardship program, including antimicrobial prescribing and resistance patterns.

  3. The organization takes action on improvement opportunities identified in its antimicrobial stewardship program.

Examples are given for some EPs and links to the Centers for Disease Control and Prevention are provided.

Electronic surveillance programs will play an integral role in maintaining compliance with this standard, if approved. Solutions like Sentri7 can optimize patient outcomes by providing real-time alerts that support core stewardship strategies outlined by organizations like IDSA and SHEA.

Click here to respond to The Joint Commission by December 30, 2015.


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  1. FACT SHEET: Over 150 Animal and Health Stakeholders Join White House Effort to Combat Antibiotic Resistance. Retrieved from the Internet December 7, 2015:

  1. The Joint Commission Proposed New Standard on Antimicrobial Stewardship. Retrieved from the Internet December 7, 2015:

Topics: Antimicrobial Stewardship

About the Author

Eileen O'Rourke has been practicing hospital-based Infection Prevention since 1984 and served as a consultant with the ECRI Institute in 2014-2015. Eileen's background also includes experience in Microbiology and a Masters in Public Health. She is certified by CBIC and the American Society of Clinical Pathologists and has been active in the Delaware Valley Chapter of APIC (Association for Professionals in Infection Control and Epidemiology), serving as Education Chair and President. Her special interest is education and she has offered multiple infection prevention inservices, including webinars.