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2020 MIPS IA_PSPA_15: Implementation of Antimicrobial Stewardship Program (ASP)

Activity ID

IA_PSPA_15

Activity Weighting

Medium

Subcategory Name

Patient Safety and Practice Assessment

Activity Description

Leadership of an Antimicrobial Stewardship Program (ASP) that measures the appropriate use of antibiotics for several different conditions (such as but not limited to upper respiratory infection treatment in children, diagnosis of pharyngitis, Bronchitis Rx treatment in adults) according to clinical guidelines for diagnostics and therapeutics. Specific activities may include:

  • Develop facility-specific antibiogram and prepare report of findings with specific action plan that aligns with overall facility or practice strategic plan.
  • Lead the development, implementation, and monitoring of patient care and patient safety protocols for the delivery of ASP including protocols pertaining to the most appropriate setting for such services (i.e., outpatient or inpatient).
  • Assist in improving ASP service line efficiency and effectiveness by evaluating and recommending improvements in the management structure and workflow of ASP processes.
  • Manage compliance of the ASP policies and assist with implementation of corrective actions in accordance with facility or practice compliance policies and facility or practice medical staff by-laws.
  • Lead the education and training of professional support staff for the purpose of maintaining an efficient and effective ASP.
  • Coordinate communications between ASP management and facility or practice personnel regarding activities, services, and operational/clinical protocols to achieve overall compliance and understanding of the ASP.
  • Assist, at the request of the facility or practice, in preparing for and responding to third-party requests, including but not limited to payer audits, governmental inquiries, and professional inquiries that pertain to the ASP service line.
  • Implementing and tracking an evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions.
  • Developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections
  • Implementing evidence-based protocols that align with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance

Validation

Leadership of an antibiotic stewardship program

Suggested Documentation

Documentation of leadership of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics and identifies improvement actions:

1) Documentation of the report of findings and specific action plan; or
2) Documentation of the development, implementation, and monitoring of patient care and safety protocols; or
3) Documentation of the on-going evaluation and monitoring of the management structure and workflow of ASP processes; or
4) Records of presentation of ASP education and training including curriculum and presentation dates; or
5) Documentation of communications regarding ASP compliance; or
6) Documentation of preparation of and/or participation in payer audits, government inquiries, or professional inquiries pertaining to the ASP; or
7) Documentation of evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions; or
8) Documentation of developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections; or
9) Documentation of the alignment of evidence-based protocols with recommendations in the Centers for Disease Control and Prevention’s Core Elements of Outpatient Antibiotic Stewardship guidance.

Examples of Additional Activities that Qualify for Attestation

Completing these alternate activities can fulfill the requirements of this Improvement Activity; and Notes

Sub-IA-1: Provide leadership of a Bio-Security, Bio-Preparedness, & Emerging Infectious Diseases (BBEID) Program;
Sub-IA-2: Provide leadership of an Antimicrobial Stewardship Program;
Sub-IA-3: Provide leadership of Outpatient Parenteral Antimicrobial Therapy Hospital Admission/Readmission Avoidance Program

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