2023 MIPS IA_PSPA_15: Implementation of an ASP

Activity ID

Activity Weighting

Subcategory Name

Activity Description

Leadership of an Antimicrobial Stewardship Program (ASP) that includes implementation of an 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 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 clinic compliance policies and hospital 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.

Objective

Suggested Documentation

Evidence of leadership of an Antimicrobial Stewardship Program (ASP) that measures the appropriate use of antibiotics for several different conditions according to clinical guidelines for diagnostics and therapeutics. Include at least one of the following elements:

1) Antibiogram and report – Documented facility-specific antibiogram and report of findings and specific action plan aligned with overall facility or practice strategic plan; OR
2) ASP patient care and safety protocols – Documentation of the development, implementation, and monitoring of patient care and safety protocols as a result of the process of operating the ASP (e.g., email communication, meeting agendas with eligible clinician’s name, staff confirmation); OR
3) ASP evaluation – Documentation of the on-going evaluation and monitoring of the management structure and workflow of ASP processes and involvement therein (e.g., email communication, meeting agendas with eligible clinician’s name, reports, staff confirmation); OR
4) ASP education and training – Records of presentation of ASP education and training including curriculum and presentation dates with eligible clinician named as one of the facilitators or presenters; OR
5) ASP policies or practices for high-priority conditions – Documentation of involvement in selecting and implementing evidence-based policy or practice aimed at improving antibiotic prescribing practices for high-priority conditions; OR
6) ASP protocols and decision supports – Documentation of developing and implementing evidence-based protocols and decision-support for diagnosis and treatment of common infections; OR
7) Alignment with CDC Core Elements of Outpatient Antibiotic Stewardship guidance – Documentation of involvement in the alignment of evidence-based protocols with recommendations in the Centers for Disease Control and Prevention’s (CDC’s) Core Elements of Outpatient Antibiotic Stewardship guidance.

Example/Information

Extensive information on antimicrobial stewardship can be found at the CDC website: https://www.cdc.gov/antibiotic-use/core-elements/index.html. Also, the CDC includes information on ASPs for different practice settings (hospital, outpatient, nursing home, etc.).