HHS, AHRQ, HAI, and CUSP
1. What are the benefits of participating?
2. What is the Comprehensive Unit-based Safety Program (CUSP)?
3. What is antibiotic stewardship?
4. What is the timeline of the project?
5. What does it cost our facility to participate in the project?
6. Who is eligible to participate?
7. Is the program targeting specific types of hospitals? Can critical access hospitals participate?
8. My organization does not currently have an electronic health record (EHR). Are we still eligible to apply for the program?
9. How much time do you think this program takes per week? Per month?
10. What is required of our facility in order to participate in the project?
11. What data will be tracked?
12. Will we need to use the NHSN AUR data metric?
13. Are we required to submit data to NHSN?
14. What is in the Team Antibiotic Review Form that needs to be submitted?
15. Do the reports need to be submitted in specific format? Is this a file-based upload?
16. Will participants have to provide protected health information (PHI) about their patients?
17. Our facility does not have an antibiotic stewardship program (ASP). Can we still participate?
18. What is your definition of “unit” for the Safety Program?
19. Will CME or other continuing education credits be provided for any of the webinars?
20. Is a contract required to participate in the project?
21. What material do I need to complete before the kickoff?
22. Who is sponsoring the project?
23. Is there a maximum number of hospitals that can participate?
24. How does this program align with the Centers for Medicare & Medicaid Services (CMS) Hospital Improvement Innovation Network (HIIN) program?

1. What are the benefits of participating?

Our antibiotic stewardship team will work closely with members of your hospital to develop or enhance your antibiotic stewardship priorities and commitments. Using evidence-based, scientific literature, coupled with practical implementation strategies, we can help your multi-disciplinary team to understand the drivers of antibiotic prescribing, improve their knowledge of antibiotic use, and identify approaches to optimizing antibiotic use. Our team of physicians and quality improvement experts has expertise in both antibiotic stewardship and the Comprehensive Unit-based Safety Program (CUSP) and will be readily accessible for coaching, technical assistance, and ongoing education. Participation in this project will assist with compliance with The Joint Commission’s Antimicrobial Stewardship Standard. Potential benefits of participation include:

  • Improve safety culture in facilities and practices
  • Enhance teamwork and communication between healthcare workers and between healthcare workers and patients/families
  • Reduce unnecessary antibiotic use
  • Improve antibiotic decision-making by frontline staff
  • Reduce Clostridium difficile infection rates
  • Regular access to experts in antibiotic stewardship and improving safety culture
  • Improve compliance with The Joint Commission requirements
  • Earn continuing education credits by participating in 15 educational webinars. Get accreditation information.
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2. What is the Comprehensive Unit-based Safety Program (CUSP)?

CUSP is a customizable quality management program that promotes communication, teamwork, and leadership engagement to support a culture of patient safety. It combines clinical best practices with systems improvements to patient safety culture.

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3. What is antibiotic stewardship?

In the past century, antibiotics have contributed significantly to the reduction in morbidity and mortality associated with many infectious diseases. They are life-saving when used appropriately, but overuse of antibiotics contributes to both the increasing rate of Clostridium difficile infections (CDI) and to antibiotic resistance in general, particularly in health facilities. The Centers for Disease Control and Prevention estimates that 30-50% of antibiotic use in hospitals is inappropriate or even unnecessary1. However, reducing the unnecessary and inappropriate use of antibiotics can reduce antibiotic resistance on both a patient level and a population level. Antibiotic stewardship (AS) refers to the coordinated efforts to improve the use of antibiotics by promoting the selection of the optimal antibiotic regimen, dose, duration of therapy, and route of administration. This model of AS will assist in the compliance of the Joint Commission’s recently announced Medication Management standard for hospitals to address antimicrobial stewardship, which became effective January 1, 2017.

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4. What is the timeline of the project?

This project asks for a one-year commitment to improve the outcomes for patients receiving antibiotics. An online stakeholder meeting will occur in November 2017 to introduce the project and train representatives from your site about antibiotic stewardship and concepts of the Comprehensive Unit-based Safety Program (CUSP).
Onboarding/orientation webinars for the project will begin in December 2017. Data collection will begin in January 2018.
Action Due Date
Complete the Hospital Letter of Commitment October 15, 2017
Assemble a multidisciplinary team within your hospital unit October 15, 2017
Register your team to use the project data portal October 31, 2017
At least one team member attends stakeholder meeting November 2017 (Date TBD)
Participate in educational programs including the onboarding/ orientation webinar series, eLearning Modules and content webinars Beginning December 2017
Regularly meet as a team to implement interventions and monitor performance January 1, 2018 until end of project
Complete survey assessments and submit hospital unit data according to the data collection schedule January 1, 2018 until end of project
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5. What does it cost our facility to participate in the project?

Participating facilities will not incur any fees to receive facilitation as a part of this project and will not receive any payment for their participation. Of note, The Joint Commission has an Antimicrobial Stewardship standard effective January 2017 that requires that all hospitals to have antimicrobial stewardship programs. Participation in the project will assist with compliance with the Joint Commission’s Antimicrobial Stewardship Standard

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6. Who is eligible to participate?

All acute care hospitals are invited to participate. Although entire hospitals are encouraged to participate, individual units or clinical services can still participate.

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7. Is the program targeting specific types of hospitals? Can critical access hospitals participate?

The program is targeting a wide variety of acute care hospitals. Critical access hospitals can participate. We will develop material targeting hospitals with different levels of, or even no, antibiotic stewardship program in place. However, we request that if a stewardship program is not already present, a physician (and if available a pharmacist) are identified to be willing to be trained to become antibiotic stewardship leads through the AHRQ Safety Program for Improving Antibiotic Use.

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8. My organization does not currently have an electronic health record (EHR). Are we still eligible to apply for the program?

Yes, facilities that do not have electronic health records are encouraged to apply. If your facility does not have an electronic health record, we are happy to discuss ways we can work with your organization to collect data.

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9. How much time do you think this program takes per week? Per month?

We anticipate that participants will likely need to spend a minimum of 4-6 hours per month on the AHRQ Safety Program for Improving Antibiotic Use. Approximately two hours would be devoted to participating in webinars. The remaining two hours would be spent having team meetings to discuss specific antibiotic-related issues and to complete Team Antibiotic Review forms.

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10. What is required of our facility in order to participate in the project?

Each site would identify a stewardship team (e.g., physician, pharmacist, nurse) to assist with overseeing work.
Activities include:
  • Participate in regular webinars and calls. Participants will receive training via webinar and participate in monthly coaching calls during which there will be open dialogue about successes and failures related to antibiotic use and CUSP implementation.
  • Collect and review data. Your stewardship team will review data on at least 10 patients receiving antibiotics on a monthly basis to determine if antibiotic use was appropriate. We will use data submitted from your existing electronic health record to collect monthly data on days of antibiotic therapy per 1,000 patient days and rates of Clostridium difficile infection. (We will also accept data on days of antibiotic therapy per 1,000 day present, or the AUR module, if you are already collecting this data or this approach works better for your facility.)
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11. What data will be tracked?

Most of the data for this project can be downloaded from your electronic medical records. The data you submit for this project will allow you to access real-time reports that detail how your unit is improving in regards to the appropriate care of your patients. As well, your data will be aggregated, anonymized, and then shared with AHRQ and other hospitals participating in the project. You will be responsible for collecting and submitting the measures listed below:
  • Days of antibiotic therapy per 1,000 patient-days for antibiotics commonly administered in the inpatient setting (monthly)
    • Can use days of antibiotic therapy per 1,000 days present, if that is more feasible for your facility
  • Clostridium difficilelaboratory event episodes per 10,000 patient-days (quarterly)
  • Team Antibiotic Review Forms completed on 10 patients per month
    • This form takes approximately 5 minutes per patient to complete and does not include any protected health information
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12. Will we need to use the NHSN AUR data metric?

We are not asking for data using the NHSN AUR data metric. However, if you already submit data to NHSN and obtaining the data for days of antibiotic therapy per 1,000 patient days is difficult, you may submit this data.

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13. Are we required to submit data to NHSN?

There is no requirement to submit data to NHSN.

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14. What is in the Team Antibiotic Review Form that needs to be submitted?

The Team Antibiotic Review forms provide a format for teams to review antibiotic use to determine if there is room for improvement for antibiotic decision-making for patients actively receiving antibiotics. We anticipate that stewardship teams will meet with frontline staff and review 10 patients per month. This can be done in one meeting or can be divided between multiple meetings. It should take approximately 5 minutes to complete the Team Antibiotic Review Form per patient. The form is available on the project website. We are not requesting any protected health information (PHI) on this form. Its main purpose is to generate discussion regarding antibiotics decisions for patients receiving antibiotic therapy.
Our goal is to make sure that people are using this focus in their thinking and they find the time to meet as a group to discuss cases. This will bring back a lot of the material covered in the webinars.

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15. Do the reports need to be submitted in specific format? Is this a file-based upload?

The Team Antibiotic Review Forms can be easily electronically uploaded to the project website. Similarly, antibiotic use data and Clostridium difficile data can be uploaded to the website. As an example, if your institution is able to generate antibiotic use data in an Excel file, the Excel file can be directly uploaded to the project website Information on data submission is available on the program website and the project team can individually discuss with you the most feasible submission process for your facility.

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16. Will participants have to provide protected health information (PHI) about their patients?

The program is only requesting de-identified information and is not requesting any PHI.

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17. Our facility does not have an antibiotic stewardship program (ASP). Can we still participate?

Yes. Training will be available for institutions both with and without ASPs. If an ASP is present, we will work with both the ASP and frontline staff so they understand how to identify defects in their healthcare setting related to antibiotic use and how to implement both technical and adaptive solutions to improve patient safety surrounding antibiotic prescribing. If an ASP is not present, we will work with clinicians who are interested in learning the principles of antibiotic stewardship to train them to become antibiotic stewards and create this expertise within your own organization.

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18. What is your definition of “unit” for the Safety Program?

For this project, a unit is an area with defined and consistent staff who care for patients. In the acute care setting it can be a clinical unit or clinical service. Individual units (e.g., MICU, general medical ward) or clinical services (e.g., hospitalist service) or entire hospitals are welcome to participate. There is also no limit to the number of participating units within an institution.

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19. Will CME or other continuing education credits be provided for any of the webinars?

Yes. Credit will be offered for each of the 15 educational webinars that will be held during the 12-month program. See accreditation details below:

Continuing Medical Education

  • The Society for Healthcare Epidemiology of America is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • Physicians: The Society for Healthcare Epidemiology of America designates this live activity for a maximum of 15 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

We have also applied for Continuing Pharmacy Education credits.

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20. Is a contract required to participate in the project?

No, a contract is not required to participate in the project. We will ask your facility’s primary contact for the project and the facility administrator to sign a participation agreement. This is not a contract; rather, it is an agreement to work with us.

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21. What material do I need to complete before the kickoff?

You need to complete a letter of commitment and an Institutional Review Board (IRB) approval form, if needed by your facility.

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22. Who is sponsoring the project?

This project is funded and guided by the Agency for Healthcare Research and Quality (AHRQ), part of the U.S. Department of Health and Human Services (HHS). The work is being conducted by Johns Hopkins University in collaboration with NORC at the University of Chicago.

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23. Is there a maximum number of hospitals that can participate?

Up to 500 hospitals will be able to participate.

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24. How does this program align with the Centers for Medicare & Medicaid Services (CMS) Hospital Improvement Innovation Network (HIIN) program?

This AHRQ Safety Program for Improving Antibiotic Use is complementary to the Hospital Improvement Innovation Network (HIIN) program. One of the HIIN core topics is reduction in Clostridium difficile bacterial infections, and includes antibiotic stewardship. The AHRQ program provides a comprehensive program to assist hospitals in reaching their goals of improved prescribing and reduction of all antibiotic-related harms, including Clostridium difficile infections. Hospitals can elect to participate in both the HIIN and AHRQ programs, and participation in the AHRQ program may help hospitals reach HIIN goals.

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