Center for Improvement in Healthcare Quality Newsletter
March 2022

News You Can Use

March Compliance Tip of the Month

March’s tip of the month is focused on the standard/requirements regarding establishment of an antibiotic stewardship program. Specifically, regarding a lack of evidence that the organization is collecting, aggregating, analyzing and acting in response to data including adherence to antibiotic prescribing guidelines.
Organizations are expected to provide evidence that the monitoring is occurring and that it is incorporated into the QAPI program. The intent behind the regulation is to monitor and improve the use of antibiotics in accordance with nationally recognized guidelines.
Both the CMS and CIHQ standards/requirements have been included for reference.

Proposed CIHQ Standard

IC-10: Establishment of an Antibiotic Stewardship Program
The organization develops and implements an antibiotic stewardship program in writing that is in accordance with nationally recognized guidelines as well as best practices and all requirements noted under 42 CFR 482.42 (b) aimed at improving antibiotic use.
  1. The organization must designate in writing the individual(s) qualified through education, training or experience in infectious disease and/or antibiotic stewardship to be the leader of the program. The appointment of this individual is the responsibility of the governing body based on recommendations of medical staff and pharmacy leadership.
  2. The program must demonstrate coordination among all components of the organization responsible for antibiotic use and resistance, including but not limited to:
    • The infection control program
    • QAPI program
    • Medical staff
    • Nursing services
    • harmacy services
  3. The program must document the evidence-based use of antibiotics in all department and services of the hospital.
  4. The program must document any improvements, including sustained improvements with regard to antibiotic use.
  5. The program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use
  6. The program reflects the scope and complexity of the services provided.
  7. The leadership of the antibiotic stewardship program is responsible for;
    • The development and implementation of a hospital-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics
    • All documentation, written or electronic, of antibiotic stewardship program activities.
    • Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as with the hospital’s infection prevention and control and QAPI programs, on antibiotic use issues.
    • Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.


§482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship Programs
The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program.
[§482.42(c)(1) The governing body must ensure all of the following:]
(ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with hospital QAPI leadership.
There are tools made available to CIHQ accredited organizations through the ARS provided resources to assist with compliance:
Resource Library – Infection Prevention and Control
  • #3025 – Policy – Antibiotic Stewardship Program
  • #3014 – Tool – Antibiotic Stewardship – Physician and Staff Information Sheet
  • #3016 – Tool – Antibiotic Stewardship Guideline for Management of Clostridium Difficile Toxin
  • #3017 – Tool – Antibiotic Stewardship Guideline for Treatment of Community Acquired Pneumonia
  • #1131 – Tool – Antibiotic Stewardship Guideline for Treatment of Skin and Soft Tissue Infections
  • #1132 – Tool – Antibiotic Stewardship Guideline for Treatment of Urinary Tract Infections
  • #1127 – Form – Antibiotic Stewardship Program Monitoring Evaluation
Staff Training Library
  • #02. Antibiotic Stewardship – Rev. 9.21

CIHQ Accreditation Survey Top Findings June 1 – December 31, 2021

CIHQ analyzes findings cited during accreditation surveys in order to track and trend the top findings. We do this primarily to evaluate whether or not ARS is supplying sufficient and effective resources to assist our facilities with compliance. This also guides the decision to add more tools and resources in order to facilitate compliance. This tracking is also used to evaluate the quality and consistency of how standards are applied and cited.
Below are the top condition-level and standard-level deficiencies cited during the last half of 2021.
CIHQ Standard Number Title Level of Severity Percentage Cited at Condition-Level
GL-04 Leadership Responsibilities Condition
*Note this standard is cited when condition-level deficiencies are cited regardless of the standard cited
RT-01 Respiratory Services Condition 23%
MM-28 Administration of Medications Condition 23%
MM-24 Preparation of Medications Condition 15%
IC-03 Infection Prevention & Control Condition 12%
CIHQ Standard Number Title Level of Severity Percentage of Surveys Cited at Standard-Level
CE-15 Compliance to the NFPA Life Safety Code Standard 96%
MR-05 Minimum Content of the Medical Record Standard 81%
IC-03 Infection Prevention & Control Policies Standard 69%
NU-03 Food Preparation & Storage Standard 69%
CE-10 Management of Utilities Standard 62%
MM-05 Storage of Medications Standard 62%
CE-19 Inspection & Testing of Life Safety Systems Standard 58%
MM-22 Medication Orders Standard 50%
CE-03 Provision of a Safe Environment Standard 46%
CE-09 Management of Supplies Standard 46%

CIHQ Announces New Disease Specific Certification – Primary Heart Attack Center

CIHQ proudly announces the launching of a new disease specific certification program for Primary Heart Attack Center. This certification is designed to recognize the provision of evidence-based best practice to patients experiencing a heart attack requiring interventional cardiac services. The standards for this disease specific certification are based on the 2021 American Heart Association Guideline for Artery Revascularization and the 2020 American Heart Association Acute Coronary Syndrome Algorithm.
For more information click on the DSC on your extranet home page. Not accredited by CIHQ? You can still become certified in any one of our programs and can get our standards and information at

CIHQ to Attend TORCH Convention in April 2022

Visit CIHQ at Booth #105 TORCH in April
CIHQ is proud to announce our Corporate Membership with the Texas Organization of Rural & Community Hospitals (TORCH) whose vision is to provide rural Texas access to the highest quality healthcare. The mission of TORCH is to be the voice and advocate for rural and community hospitals, and to provide leadership in addressing needs and issues that arise. We believe this partnership will serve CIHQ and TORCH through shared values of providing the best customer service, using data as a basis for setting policy and improving outcomes, and an open dialogue. CIHQ and TORCH strive to be prepared for changes, maintain growth and to build strategic relationships that enhance effectiveness.
Stop by and see CIHQ at Booth 105 during the TORCH Spring Conference & Trade Show in Dallas, April 19-21, 2022. This distinctive event is the premiere source for quality education and networking for rural hospital leaders and decision makers in Texas. Learn about current issues, reinforce old relationships, and build new ones, show your support for rural and community hospitals. Guest speakers include John M. Zerwas, MD, Executive Vice Chancellor for Health Affairs, The University of Texas System, Texas Senator Lois Kolkhorst, and Benjamin Anderson, Vice-President, Rural Health and Hospitals at Colorado Hospital Association.