HHS, AHRQ, HAI, and CUSP
General Program Questions
1. What are the benefits of participating?

Our antibiotic stewardship team will work closely with members of your facility to develop or enhance your antibiotic stewardship priorities and commitments. Using evidence-based, scientific literature and practical implementation strategies, we can help your multidisciplinary team understand the drivers of antibiotic prescribing, improve its knowledge of antibiotic use, and identify approaches to optimizing antibiotic use.

Our team of physicians and quality improvement experts has expertise in antibiotic stewardship and will be readily accessible for coaching, technical assistance, and ongoing education. Full participation in this program will assist with compliance with the Centers for Medicare & Medicaid Services’ (CMS) requirement for long-term care (LTC) facilities to implement antibiotic stewardship programs by 2020. Potential benefits of participation include—

  • Enhancing teamwork and communication
  • Reducing unnecessary antibiotic use
  • Reducing Clostridium difficile infection (CDI) rates
  • Improving resident and family satisfaction
  • Earning free continuing education credits for attending educational webinars
  • Earning a Certificate of Participation for facilities that successfully submit requested data
  • Earning a Certificate of Completion for facilities that complete the entire program.
2. What is antibiotic stewardship?
Antibiotics decrease morbidity and mortality when used appropriately, but overuse of antibiotics contributes to both the increasing rate of CDI and the emergence of antimicrobial resistance. Antibiotic stewardship 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, when antibiotics are needed.
3. What does it cost our facility to participate in the program?
Participation in the program is free. Participating facilities will not incur any fees to receive facilitation as a part of this program and will not receive any payment for their participation.
4. What is the timeline of the program?
This program asks for a 1-year commitment. Onboarding/orientation Webinars to introduce the program and train representatives from your site about antibiotic stewardship will begin in December 2018. Data collection will begin in January 2019.
Action Due Date
Assemble a multidisciplinary team within your facility November 30, 2018
Complete the Letter of Commitment
Register your team to use the program data portal
Participate in educational programs including the onboarding/orientation Webinar series, Narrated Presentations, and content Webinars Beginning December 2018
Regularly meet as a team to implement interventions and monitor performance January 1, 2019, until end of program
Complete survey assessments and submit facility data according to the data collection schedule
5. What is required of our facility in order to participate in the program?
Each site would identify a stewardship team (e.g., nurse, physician, consulting pharmacist) to assist with overseeing work. Activities include—
  • Participating in regular 30 minute Webinars. Participants will receive training via Webinars held once or twice per month.
  • Determining and implementing approaches to improve antibiotic use. Using approaches discussed in the Webinars, stewardship teams will develop and implement approaches for a daily review of residents who are receiving antibiotics and optimize antibiotic therapy. In addition, teams will participate in assessing issues with how antibiotics are prescribed and administered in their facility and developing improvement plans.
  • Collecting and reviewing data. Your stewardship team and frontline staff are encouraged to work together to review antibiotic use data.
6. How much time does this program take per month?
We anticipate that the stewardship team and other participating clinical staff will likely need to spend a minimum of 4 hours per month on the AHRQ Safety Program for Improving Antibiotic Use. Approximately 1 hour would be devoted to participating in Webinars. The remaining 3 hours would be spent having team meetings to discuss specific antibiotic-related issues and working through the Four Moments of Antibiotic Stewardship Tool.
7. When is the deadline to enroll?
The deadline to enroll in the program is November 30, 2018.
8. Is a contract required to participate in the program?

No, a contract is not required to participate in the program. To apply for the program your facility’s administrator or other primary contact will need to complete the online application form available at https://safetyprogram4antibioticstewardship.org

The program then requests a letter of commitment signed by an administrator, director of nursing, and/or medical director or other physician champion. This is not a contract; rather, it is an agreement to work with us. We ask for these signatures to ensure support for the program from the facility’s leadership and to approve the minimum time commitment of 4 hours per month. However, the actual program commitments/requirements will be fulfilled by the stewardship team and frontline staff.

9. Is a data use agreement (DUA) required to participate in the program?

No, a DUA is not required for participation in the program. The data are being collected both for program assessment purposes and as a tool for each site’s own quality improvement efforts. Each site should use the data it collects to evaluate its antibiotic use and antibiotic stewardship efforts. NORC and Johns Hopkins Medicine will use the collected data to assess the adoption and effectiveness of the program overall. Additionally, each site can compare its antibiotic use to similar facilities.

Since the program is only requesting de-identified information and is not requesting any PHI, a data use agreement is not required for participation in this program. However, if your facility determines that it still needs a DUA to define the transaction, we can provide a template for your review.

10. What material do I need to complete before the program begins?

You need to complete the online application and a letter of commitment. The letter of commitment should be signed by an administrator, director of nursing, and/or medical director or other physician champion.

This program does not involve human subjects research, so no IRB approval is required. Your facility should be able to frame this program as a quality improvement study. Johns Hopkins Medicine has determined this program is not Human Subjects Research (Johns Hopkins IRB #IRB00129058). If your facility should require an IRB submission for informational purposes, we will be glad to help you as needed.

11. Who is sponsoring the program?
This program 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 Medicine’s Armstrong Institute for Patient Safety and Quality in collaboration with NORC at the University of Chicago.
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Data Collection
12. What data are being collected? Please see the table below.
Data Collection Tools
Tool Purpose To Be Completed By Estimated Completion Time Frequency of Data Collection
One Day Monthly Point Prevalence Survey To determine proportion of appropriate antibiotic use CUSP team in conjunction with antibiotic stewardship (AS) team Monthly
Number of antibiotic starts
Nursing Home Survey on Patient Safety (NHSOPS) To collect information on resident safety issues AS team members 15 minutes per survey Twice. Completed at beginning and end of program.
EHR Clinical Data Extracts
Tool Purpose To Be Completed By Estimated Completion Time Frequency of Data Collection
Days of antibiotic therapy (DOT) per 1,000 resident-days* To evaluate the changes in antibiotic usage, clinical outcomes, and other effectiveness measures Extracted from Electronic Health Record (EHR). See below for more information 60 minutes per quarter. May vary, depending on hospital IT/data collection infrastructure Monthly
Number of urine cultures per 10,000 resident-days Extracted from EHR 20 minutes per quarter Quarterly
Number of C. difficile positive microbiological tests per 10,000 resident-days 20 minutes per quarter

*For more information on the DOT per 1,000 resident-days measure, please see below.

DOT per 1,000 resident-days measure
Numerator: We are requesting days of antibiotic therapy for commonly used inpatient antibiotics. Antibiotic administration or ordering data is acceptable for the numerator, but not purchasing data.
Denominator: We are requesting monthly census data as resident or patient days of care. This denominator may be familiar to many long-term care facilities from their facility’s infection control work and may already be calculated on a monthly basis. It represents the number of residents on a unit for each day of the month.
PLEASE NOTE: DOT per 1,000 resident-days is different from the National Healthcare Safety Network (NHSN) Antimicrobial Use and Resistance metric. You do not need to submit data to the NHSN Antimicrobial Use and Resistance (AUR) module to participate in this program. If you are an institution that submits NHSN AUR data and would prefer to submit that same data to our program Web site, that is also acceptable.
13. Will participants have to provide protected health information (PHI) about their residents?
The program is only requesting de-identified information and is not requesting any PHI.
14. For what purpose will the data be used?
The data are being collected as a tool for quality improvement efforts and program assessment purposes. Each site should use the data it collects to evaluate its antibiotic use and antibiotic stewardship efforts. NORC at the University of Chicago and Johns Hopkins Medicine will use the collected data to assess the adoption and effectiveness of the program overall. Additionally, each site can compare its antibiotic use to similar facilities. The program is collecting only de-identified data. Aggregate LTC facility antibiotic use data will be shared with similar participating LTC facilities for comparison purposes only. Individual participating LTC facilities will not be identified.
15. Where specifically will our data be shared, and will it be “published” with our LTC facility identifiers?
The program only collects de-identified data. Your data will be aggregated, anonymized, and then shared with AHRQ and other similar LTC facilities participating in the program for comparison purposes only. Individual LTC facilities will remain anonymous.
16. Are we required to submit data to NHSN? Will we need to use the NHSN AUR data metric?
There is no requirement to submit data to NHSN. We are not asking for data using the NHSN AUR data metric. However, if you already submit data to NHSN’s AUR Module and obtaining the data for days of antibiotic therapy per 1,000 resident days is difficult, you may submit AUR data.
17. Do the data need to be submitted in a specific format? Is this a file-based upload?
The antibiotic use data and Clostridium difficile data can be uploaded to the Web site. As an example, if your facility is able to generate antibiotic use data in an Excel file, the Excel file can be directly uploaded to the program Web site. The program will provide sample Excel files to assist with data collection. Information on data submission is available on the program Web site and the national program team can individually discuss with you the most feasible submission process for your facility. Participating LTC facilities will be allowed to fax data if they are unable to load it to the program Web site.
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Eligibility
18. Who is eligible to participate?

All of the following facilities are eligible to participate:

  • Skilled, residential, and continuing care facilities
  • Skilled nursing facilities (SNFs) (may include adjoining long-term acute care hospital [LTACH] or ventilator unit)
  • Dementia care facilities

This program is not designed for standalone LTACHs, assisted living facilities, rehabilitation facilities, adult day care, home health programs, or facilities specializing in the care of developmentally disabled or pediatric patients. However, if any of these settings or units are adjoining eligible facilities, they may still be included in the program.

Eligible LTC Facilities Ineligible LTC Facilities
  • Nursing homes
  • Dementia care facilities
  • Residential and continuing care facilities
  • Skilled nursing facilities (SNFs)
    • including SNFs with rehab beds or adjoining LTACH or ventilator unit
  • Stand-alone LTACHs
  • Adult day care
  • Home health
  • Pediatric or developmentally disabled populations
  • Dedicated rehabilitation facilities
  • Assisted living facilities
19. My organization does not currently have an electronic health record. Are we still eligible to apply for the program?
Yes, facilities with and without 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.
20. Our facility does/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 a facility already has an ASP, we will work with both the ASP and frontline staff so they understand how to identify approaches to optimize antibiotic use and how to implement both technical and adaptive solutions to improve resident 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 organization.
21. Can facilities participate without a single designated antibiotic stewardship leader?
For this program to be successful, each facility needs to have a leader or champion. The leader may be the medical director, other physician, nurse, infection prevention and control professional, pharmacist, or an administrator.
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Educational Webinars
22. Are the monthly Webinars more about antibiotic stewardship or clinical instruction for management of infectious diseases?
The monthly Webinars focus on (1) how to establish and/or maintain a well-functioning and successful antibiotic stewardship program; (2) how to improve communication between prescribers and frontline staff, as well as behaviors and attitudes related to antibiotic prescribing; and (3) discussions of best practices for common infectious syndromes (e.g., urinary tract infections and respiratory infections).
23. Who should participate in the Webinars?
The stewardship lead(s) and clinical staff should participate in the monthly Webinars; this includes all individuals who are responsible for ordering, administering, or monitoring the use of antibiotics, including nurses, nurse practitioners, physicians, pharmacists, and physician assistants. We recognize that not all frontline clinical staff can be on each Webinar due to clinical responsibilities; thus, we recommend designating at least one or two frontline providers to attend each Webinar in real time and report back to the rest of the team on the topic covered. The slides and accompanying facilitator guides for all Webinars will be available on the program Web site for staff who are unable to be on the live Webinars. In addition, all participating staff will be provided with a user name and password to access the program Web site, which contains all educational content related to the program.
24. Will continuing education credits be provided for any of the Webinars?
Yes, credit will be offered for attending each of the 15 educational Webinars that will be held during the 12-month program. Individuals who complete the entire series of Webinars will be able to earn a certificate indicating completion.
25. How does this program relate to the CMS National Nursing Home Quality Care Collaborative led by the Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs)?
The AHRQ program is complementary to the QIN-QIO work. This AHRQ program emphasizes both antibiotic stewardship program development and integration of antibiotic stewardship work into the daily work of frontline staff as an approach to maintaining improvement in prescribing practice over time. The AHRQ program provides Webinars and other resources to assist participating LTC facilities in reaching their goals of improved prescribing and reducing CDI rates. LTC facilities can elect to participate in both programs.
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