The hospital establishes antibiotic stewardship as an organizational priority through support...

(1)

The antibiotic stewardship program reflects the scope and complexity of the hospital services provided.

(2)

The hospital demonstrates that an individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership.

(3)

The leader(s) of the antibiotic stewardship program is responsible for the following: - Development and implementation a hospitalwide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics - All documentation, written or electronic, of antibiotic stewardship program activities - Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as with the hospital’s infection prevention and control and quality assessment and performance improvement programs, on antibiotic use issues - Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures

(4)

The governing body ensures all antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the hospital's quality assessment and performance improvement leaders.

(5)

The hospitalwide antibiotic stewardship program: - Demonstrates coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the quality assessment and performance improvement program, the medical staff, nursing services, and pharmacy services. - Documents the evidence-based use of antibiotics in all departments and services of the hospital. - Documents any improvements, including sustained improvements, in proper antibiotic use.

(6)

The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use.

(7)

The governing body ensures that systems are in place and operational for the tracking of all antibiotic use activities in order to demonstrate the implementation, success, and sustainability of such activities.