Healthcare Facility Compliance 15 items
Antimicrobial Stewardship Program (ASP) Audit
Audit of a hospital antimicrobial stewardship program against the CDC Core Elements and the CMS infection prevention and antibiotic stewardship Condition of Participation.
CMS 42 CFR 482.42CDC Core Elements of Hospital ASPTJC MM.09.01.01
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Leadership & Accountability
- Has facility leadership committed dedicated financial and human resources to the stewardship program in a written statement? *
- Is a physician leader identified and accountable for antimicrobial stewardship program outcomes? *
- Is a pharmacist leader appointed with responsibility to improve antibiotic use (pharmacy expertise)? *
- Does the program integrate with the facility infection prevention and control and quality/QAPI committees? *
Action & Interventions
- Is a facility-specific antibiotic use policy or treatment guideline in place for common indications? *
- Is prospective audit with feedback (external review of therapy) performed for targeted antibiotics? *
- Is a formal antibiotic 'time-out' or 48-72 hour reassessment documented for continued therapy? *
- Are preauthorization requirements enforced for restricted or broad-spectrum agents?
Tracking & Reporting
- Are antibiotic use metrics (e.g., days of therapy per 1,000 patient-days) tracked over time? *
- Is antibiotic use data reported to the CDC NHSN Antimicrobial Use and Resistance (AUR) module?
- Is a facility antibiogram produced at least annually and shared with prescribers? *
- Are stewardship reports provided to prescribers, nurses, and leadership? *
Education & Culture
- Is annual antimicrobial stewardship education provided to clinicians and pharmacists? *
- Are patients and families given education on appropriate antibiotic use when relevant?
- Is C. difficile infection rate monitored as a program outcome measure? *
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