Acute Care

Regulatory Requirements

The Joint Commission 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 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 detail, visit

In addition, Center for Medicare and Medicaid Services (CMS) proposed a new set of Condition of Participation (CoP) in June 2016 to improve patient cares for hospitals and critical access hospitals (CAH).   As part of the proposal, hospital and CAH are required to develop and maintain an ASP to optimize antibiotic use.  To view the full proposed CMS rules, visit  The proposed rule for hospitals and CAH is expected to be finalized by the end of 2017.

Page last reviewed: August 13, 2019