Merry Christmas and Happy New Year everyone.

I am the pharmacy director at a rural Critical Access Hospital in Northwest Ohio and am working through the new TJC standard for Antimicrobial Stewardship, MM.09.01.01 that go into effect on 1/1/2023.

I am tempted to ask a broad question about how other hospitals are meeting the new/revised EPs but will keep my questions more focused on the EPs that seem more daunting.

1. How do other hospitals drive order set use? We have a large number of providers who avoid order sets and freely enter orders, including antibiotic orders. One option that I've thought of is to only include antibiotics on disease specific order sets and limit the availability to order freely.

2. Do other hospitals monitor order set use and order set compliance? Since order sets are evidence based orders, it makes sense to monitor their use. It is unclear to me however how I would go about monitoring order set compliance without this being a significant time burden.

3. Does anyone have practical examples of how they educate providers on antibiotic order sets? Is this something that is done upon hire/privileging?

4. Lastly, how about appointing a physician or pharmacist lead? Has anyone appointed a non-physician for this role?

Thanks in advance for your help!

Rachel Durham PharmD RPh
Director of Pharmacy
Fulton County Health Center