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Antimicrobial Stewardship Program

MCN Question of the Week

Antimicrobial Stewardship Program


Are Joint Commission accredited hospitals required to have antimicrobial stewardship programs?


Yes.  Under the new Medication Management standard MM.09.01.01, hospitals are required to have an antimicrobial stewardship program.  This standard is effective as of January 1, 2017.

The Joint Commission requires that a hospital’s antimicrobial stewardship program:

  • Is developed by a multidisciplinary team
  • Has a single leader responsible for the program’s outcomes
  • Appoints single pharmacist as the leader who is responsible or working to improve antibiotic use
  • Is based on current scientific literature
  • Is built around the core elements indentified in the Centers for Disease Control and Prevention’s Core Elements of Hospital Antibiotic Stewardship Programs
  • Includes education programs for staff that address antimicrobial ordering, dispensing, administration, and monitoring
  • Includes education programs for families about the appropriate use of antimicrobial medications, including antibiotics
  • Is monitored, analyzed and findings reported to clinicians; performance improvement opportunities are identified and implemented
  • Uses organization-approved multidisciplinary policies and procedures/protocols

Related Products from MCN Healthcare:

Pharmacy and Medication Management Manual



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