Antimicrobial Stewardship Standards: A Comparison of Centers for Medicare & Medicaid Services and Joint Commission Requirements

Antimicrobial stewardship programs will soon become nationally mandated.1 Following President Barack Obama’s 2014 executive order to combat antibiotic-resistant bacteria, the White House released a National Action Plan in 2015 that included targets to implement antimicrobial stewardship in all healthcare facilities (Figure).^1,2 The Centers for Medicare & Medicaid Services (CMS) recently published updated Conditions of Participation (CoP) for implementation of formal antimicrobial stewardship programs in all hospitals and critical access hospitals participating in Medicare and Medicaid programs.³ Although a specific date for implementing the new CoP has not been published, the general timeline, according to the National Action Plan, estimates this to be done by 2018.^1,3

In the meantime, a separate accrediting body, the Joint Commission, will begin assessing institutional antimicrobial stewardship programs (ASPs) on January 1, 2017, as part of their accreditation survey.⁴ The Joint Commission is an independent organization whose certification generally signifies compliance with CMS.⁵ Both CMS and the Joint Commission have created their own ASP guidelines.^3,4 This article provides an overview of CMS CoP and Joint Commission standards, and will highlight their similarities and differences.

CMS CONDITIONS OF PARTICIPATION

In 21 of the 128 pages that detail changes to the CoP for participating hospitals and critical access hospitals, CMS discusses the rationale and requirements for antimicrobial stewardship activities.³ Antimicrobial stewardship is embedded within the infection-control and prevention requirements; however, CMS emphasizes that although the two should be fostered independently, they should work together toward common goals. Rather than outline specific criteria, CMS states that institutions should develop and implement an ASP based on national guidelines. These guidelines can include recommendations put forth by the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the American Society of Health System Pharmacists.

Although the general text of the CMS CoP is broad, there are certain requirements mentioned specifically by CMS:

1. Develop antimicrobial stewardship policies and procedures
2. Demonstrate an active ASP implemented hospital-wide
3. Improve coordination among all stakeholders involved in antimicrobial use and preventing bacterial resistance
4. Promote evidence-based antimicrobial use
5. Reduce adverse effects associated with antimicrobial use, specifically C. difficile infection (CDI) and antibiotic resistance.

Surveyor tools are under development, but CMS states the following three goals will be assessed:

1. Demonstrates interdisciplinary coordination among all players involved in antibiotic use and activities contributing to antimicrobial resistance
2. Documents evidence-based use of antimicrobials
3. Demonstrates improvement in appropriate antimicrobial use, including reduction of CDI and bacterial resistance.

CMS recommends appointing a dedicated ASP leader with expertise in infectious diseases or antimicrobial stewardship who will be accountable for programmatic success. In addition to meeting the goals and requirements outlined above, this leader is also responsible for documenting all activities of the ASP and communicating with and educating all relevant hospital staff regarding appropriate antimicrobial use and resistance issues.

THE JOINT COMMISSION

Aside from brevity, the biggest difference between the Joint Commission standards for antimicrobial stewardship and the CMS CoP is the the former is much more specific, as can be seen on the Table on the next page. Therefore, compliance with the Joint Commission would ensure an institution has also met the CoP proposed by CMS. Unlike CMS, in which antimicrobial stewardship was combined with infection prevention, the Joint Commission categorizes ASP under medication management.^3,4 Like CMS, the currently published requirements apply to hospitals and critical access hospitals. In addition, Joint Commission standards will be evaluated in nursing care centers.⁴

There are eight requirements put forth by the Joint Commission that incorporate the general CMS requirements. A principal Joint Commission distinction is the requirement for patient education regarding the appropriate use of antimicrobial therapy. Additionally, there are more substantial requirements for data collection, analysis, and reporting. In terms of programmatic requirements, the Joint Commission cites the CDC Core Elements of Hospital Antibiotic Stewardship Programs,⁶ stating, “The Joint Commission recommends that organizations use this document when designing their antimicrobial stewardship program.”⁴ Part of the CDC’s Core Elements includes documenting indications for all antimicrobials and reassessing antibiotic use after 48 hours for appropriateness.⁶ Joint Commission ASP standards require use of multidisciplinary protocols, such as formulary restrictions; guidelines for therapy in specific infections, both in adult and pediatric populations; and plans for converting intravenous antibiotics to oral therapy. Given the concise presentation of the Joint Commission standard, requirements are not listed here. Readers are encouraged to examine the document directly (www.jointcommission.org/prepublication_standards_ antimicrobial_stewardship_standard).

CONCLUSIONS

The National Action Plan to Combat Antibiotic- Resistant Bacteria intends for healthcare institutions and providers to reduce inappropriate antimicrobial use among inpatient and outpatient populations by 20% and 50%, respectively.¹ The CMS and Joint Commission mandates are in place as both enforcement and to guide institutions toward success. Reducing inappropriate antimicrobial use will help mitigate the threat of antibiotic-resistant bacteria and CDI. By 2020, the National Action Plan’s goals are to reduce CDI by 50% and to reduce hospital acquisition of carbapenem- resistant Enterobacteriaceae by 60%.¹ Although ambitious, achieving these metrics is important for patient care and for maintaining healthy communities, locally and globally.

Table. Joint Commission and CMS Requirements for Antimicrobial Stewardship

REQUIREMENT

CMS

JOINT COMMISSION

Program implementation

ASP should be implemented based upon national guidelines and should promote evidence-based usage of antimicrobials.

The ASP should include core elements as defined by the CDC and utilizes multidisciplinary protocols.

Committee members

Unspecified. The program should promote a coordinated multidisciplinary approach that includes all staff and prescribers involved in antibiotic selection, administration, and monitoring.

The organization should have a multidisciplinary antimicrobial stewardship team with an ID physician, pharmacist, infection preventionist, and practitioner.

Organizational buy-in

Hospital leadership should establish an ASP as an organizational priority.

The organization should establish an ASP as a priority and provides necessary resources.

Leadership

A program leader with appropriate expertise in infectious diseases and/or antimicrobial stewardship should be appointed.

One leader should be responsible for program outcomes.

Documentation

All stewardship activities should be documented, including evidence-based use of antibiotics

ASP data should be collected and analyzed.

Program monitoring

Unspecified

The ASP should track antibiotic resistance and antibiotic prescribing patterns.

Reporting

Unspecified

ASPs should report metrics monitored to relevant healthcare providers

Improvement

The program should demonstrate improvement in appropriate antibiotic use.

The program should act upon opportunities for improvement as identified through program monitoring.

Patient education

Unspecified

Patients and their families should be educated, as needed, regarding appropriate use of antimicrobials.

Provider education

Training and education should be provided to relevant staff and prescribers regarding practical applications of an ASP.

Staff and providers involved in antibiotic orders from initiation to administration and monitoring should receive education about antibiotic resistance and stewardship.

ASP, antimicrobial stewardship program; CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare & Medicaid Services; Infectious disease

Zahra Kassamali currently co-directs the Antimicrobial Stewardship program at UW Medicine, Valley Medical Center, in the greater Seattle metropolitan area and holds an affiliate faculty position with the School of Pharmacy at the University of Washington. Prior to her work in Seattle, Dr. Kassamali held clinical and faculty positions in infectious diseases at UCLA and at the University of Illinois, Chicago.

REFERENCES

1. National Action Plan for Combating Antibiotic-Resistant Bacteria. The White House website. www.whitehouse.gov/sites/default/files/ docs/national_action_plan_for_combating_antibotic-resistant_ bacteria.pdf. Published March 2015. Accessed October 11, 2016.

2. Executive Order — combating antibiotic-resistant bacteria [press release]. Washington, DC: The White House Office of the Press Secretary; September 18, 2014. www.whitehouse.gov/the-pressoffice/ 2014/09/18/executive-order-combating-antibiotic-resistantbacteria. Accessed October 11, 2016.

3. Department of Health and Human Services; Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care. Federal Register website. http://federalregister.gov/a/2016-13925. Published June 16, 2016. Accessed October 6, 2016.

4. Prepublication standards: new antimicrobial stewardship standard. The Joint Commission website. www.jointcommission.org/ prepublication_standards_antimicrobial_stewardship_standard/. Published June 22, 2016. Accessed October 6, 2016.

5. About the Joint Commission. The Joint Commission website. www. jointcommission.org/about_us/about_the_joint_commission_main. aspx. Accessed October 13, 2016.

6. Core elements of hospital antibiotic stewardship programs.CDC website. www.cdc.gov/getsmart/healthcare/implementation/coreelements. html. Updated May 25, 2016. Accessed October 13, 2016.