Pharmacy News

By Derek Vander Horst, Pharm.D., BCPS, PGY2 infectious diseases pharmacy resident, Munson Medical Center 

I am sure by now you have heard rumblings of new regulations that would require all acute healthcare facilities to have a formal antimicrobial stewardship program (ASP) to improve and monitor how antimicrobials are prescribed within their institution. As of Jan. 1, 2017, The Joint Commission (TJC) followed through on its promise and put these requirements into place. If you have been wondering what a survey from TJC will look like, I am here to help. TJC recently released a new accreditation survey guide for healthcare organizations in 2017 outlining what institutions may expect in relation to the new ASP regulations.1 This article is aimed at assisting you in understanding what materials regarding antimicrobial stewardship you will need to be prepared for a survey from TJC.  


Document List for TJC 2017 Accreditation Survey Guide for Antimicrobial Stewardship:

TJC has added several ASP requirements to the necessary document packet that must be presented to the survey team upon arrival at your institution. Many of these documents are utilized in several different sections of TJC’s survey. TJC surveyors will expect to see proof of the following upon review of your document packet:1

1. Document(s) describing how the institution utilizes the Center for Disease Control and Prevention’s (CDC’s) Core Elements of Hospital Antibiotic Stewardship2

2. Institution specific ASP protocols

a. Policies and procedures for ASP-specific actions (i.e., restricted antimicrobial lists, prospective audit and feedback, etc.)

b. Individuals on a multidisciplinary team responsible for antimicrobial stewardship and their corresponding functions

c. Institution-specific order sets for common infectious diseases (i.e., pneumonia, urinary tract infections, etc.)

3. Institution specific ASP metrics

a. Days of therapy, defined daily doses, cost, etc.

4. Institution specific ASP reports documenting improvement

5. Specific lists of patients that are prescribed antimicrobials to be utilized in the tracer activity. Patient lists will only be needed for the week of the survey and no retrospective computer-generated lists are necessary. These specific patients include:

a. Emergency department patients who are prescribed antimicrobials

b. Hospitalized patients that will be discharged on antimicrobials

c. Ambulatory and/or clinic patients who are surveyed under the hospital program that are prescribed antimicrobials


Individual and System Tracer Activities:

A “tracer” is a specific patient that a surveyor will follow throughout the patient’s care at your institution. During the tracer, TJC will expect to see a few new interventions in regards to your hospital’s ASP. TJC will want to ensure that education is provided on the appropriate use of antibiotics to any patients prescribed antimicrobials in the following settings: the emergency department, affiliated ambulatory care clinics being surveyed under the hospital program and/or hospitalized patients that will be discharged on antimicrobials.1 TJC will only interview patients and/or their families to ensure they have been provided education on antimicrobials if they are being discharged on them.1 For informational handouts on patient education, I encourage you to search the CDC Get Smart About Antibiotics website.3 During this tracer activity, the surveyors will interview any staff they come in contact with to ensure they have received education on antimicrobial resistance and the hospital’s ASP. Of note, during the competence assessment section of your survey TJC will want to learn about your formal educational and training processes for your staff utilized in your institution.1 They will expect to see some aspect of formal education to all the staff on antimicrobial resistance and stewardship but will not be reviewing human resource records or medical staff records related to this subject.


Leadership and Data Management:

Your survey team will also review your institution’s ASP metrics. TJC would like to see some data and reports showing improvement in antimicrobial stewardship. Possible metrics are outlined in the CDC’s Core Elements of a Hospital Antibiotic Stewardship Program. Included in these metrics, TJC would like to see data documenting antimicrobial stewardship improvement; if your data shows that this improvement is not necessary, ensure that the surveyors are made aware. While meeting with your institution’s leadership, TJC will likely discuss these metrics as well as how the institution’s leadership can demonstrate that antimicrobial stewardship is a priority.1


There are still many questions surrounding these new regulations; however, at the end of the day, we have to remember the TJC’s intent. Antimicrobial resistance is a worldwide crisis that we as healthcare professionals must combat for the sake of our patients. If you have further questions, I urge you to explore the CDC’s Core Elements of Hospital Antibiotic Stewardship Programs and TJC Accreditation Survey Guide. I also recommend looking at the Michigan Pharmacist’s Association’s webpage on Antimicrobial Stewardship, which includes guidance for starting and maintaining an ASP, and provides contact information for ASP experts in Michigan.4 May the Force be with you.



  1. The Joint Commission. Accreditation Survey Activity Guide for Health Care Organizations, Issue Date: February 6, 2017. The Joint Commission website. Accessed February 2017.
  2. U.S. Department of Health and Human Services. Core Elements of Hospital Antibiotic Stewardship. Centers for Disease Control and Prevention website. Accessed February 2017.
  3. U.S. Department of Health and Human Services. Get Smart About Antibiotics Week. Centers for Disease Control and Prevention website. Accessed February 2017.
  4. Michigan Pharmacists Association. Antimicrobial Stewardship. Accessed February 2017. 


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