REGULATORY REQUIREMENTS

The Joint Commission (TJC) Medication Standard MM.09.01.01 became effective on January 1, 2017.  This medication standard mandates hospitals develop antimicrobial stewardship program (ASP) based on current scientific literature.  It outlined 8 Expected Performance (EP) measures in which institutional leadership should establish ASP as a priority, ASP include the set of CDC-recommended core elements, and ASP uses organization-approved treatment protocols.  For additional details on this original standard, visit https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf.

TJC has since revised and expanded these requirements for all Joint Commission–accredited hospitals and critical access hospitals. Effective January 1, 2023, there will be 12 new and revised EP measures that address antibiotic stewardship. To read more about these updated standards, visit https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_antibioticstewardship_july2022_final.pdf.

In addition, Center for Medicare and Medicaid Services (CMS) finalized a new set of Condition of Participation (CoP) in September 2019 to improve patient cares for hospitals and critical access hospitals (CAH).   As part of the new CoP, hospital and CAH are required to develop and maintain an ASP to optimize antibiotic use.  To view the new CMS CoP, visit https://www.govinfo.gov/content/pkg/FR-2019-09-30/pdf/2019-20736.pdf. The relevant sections on antimicrobial stewardship program appear on page 51820 [42 CFR § 482.46 (b)] for hospitals and page 51828 [42 CFR § 485.640 (b)] for critical access hospitals. CMS interpretive criteria (updated 7/6/22) can be found here.