New & Revised Antibiotic Stewardship Requirements Announced by TJC

on the radar alert

New and revised Antibiotic Stewardship requirements will be going into effect in January 2023 for Joint Commission Hospital and Critical Access Programs. These revisions are to align requirements with federal regulations and current recommendations from scientific and professional organizations.

The revisions include the following new or modified requirements. We have noted the new requirements in bold:

  • Providing financial resources to support the antibiotic stewardship program.
  • Designating a leader of the antibiotic stewardship program and defining their responsibilities to include documenting new or sustained program improvements and providing competency-based training for staff.
  • Documenting the evidenced based use of antibiotics in all departments and services of the organization.
  • Establishing a multidisciplinary committee to guide the antibiotic stewardship program.
  • Establishing a hospital wide antibiotic stewardship program to address inappropriate antibiotic use.
  • Evaluating alignment to evidence-based guidelines for the most common indications for antibiotic use.
  • Collecting, analyzing, and reporting antibiotic stewardship program data for leadership and prescribers.
  • Monitoring antibiotic use by analyzing data on days of therapy per 1000 days present or 1000 patient days, or by reporting antibiotic use data to the National Healthcare Safety Network’s Antimicrobial Use Option of the Antimicrobial Use and Resistance Module.
  • Optimizing antibiotic prescribing by implementing preauthorization for specific antibiotics and/or prospective review and feedback regarding antibiotic prescribing practices.
  • Implementing at least two evidence-based guidelines to improve antibiotic use and evaluating adherence to at least one of them.

There are additional editorial revisions including renumbering EPs, clarifying language, and additional notes. Details for the Hospital and Critical Access Programs can be found in the Prepublication Standards located here:  https://www.jointcommission.org/standards/prepublication-standards/new-and-revised-requirements-addressing-antibiotic-stewardship-for-hospital/

The E-dition manuals with the new standards will be updated in Fall 2022.

Please reach out to the C&A team with further questions or for assistance with your regulatory compliance needs.

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