CMS SOM App. A, Tag A-0761

(i) 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 QAPI program, the medical staff, nursing services, and pharmacy services;

Interpretive Guidelines §482.42(b)(2)(i)

Hospitals must develop and implement appropriate antibiotic stewardship interventions to

address issues identified through their assessment activities and then monitor the effectiveness of

interventions through further data collection and analysis. Hospitals should improve their

internal coordination among all components responsible for antibiotic use and reducing the

development of resistance, including, but not limited to, the antibiotic stewardship programs, the

infection prevention and control program, the QAPI program, the medical staff, nursing

services, laboratory services, and pharmacy services. Hospitals must promote evidence-based

use of antibiotics, to reduce the incidence of adverse consequences of inappropriate antibiotic

use including, but not limited to, treatment failures, C. difficile infections (CDIs), and growth of

antibiotic resistance in the hospital overall.

The hospital must implement and maintain an active and hospital-wide antibiotic stewardship

program as an effective means to improve hospital antibiotic-prescribing practices and thereby

curb patient risks for adverse drug events, treatment failures, and potentially life-threatening,

antibiotic-resistant infections, including CDIs. A robust antibiotic stewardship program must be

coordinated with the hospital’s overall infection prevention and control program to address

healthcare-acquired infections and antibiotic resistance.

Survey Procedures §485.640(b)(2)(i)

• Review the hospital’s antibiotic stewardship policies and procedures for evidence

that the hospital has a process in place for coordination among all components of the

hospital responsible for antibiotic use and resistance, including, but not limited to, the

antibiotic stewardship program, the infection prevention and control program, the

QAPI program, the medical staff, nursing services, and pharmacy services.