healthcare-associated infections (hai) program

CDPH HAI Antimicrobial Stewardship Program (ASP) Honor Roll Minimum Documentation

Minimum Documentation Overview

New and renewal applicants for all designations (Bronze, Silver, and Gold) are required to upload minimum documentation requirements.

Upgrades: Upgrade applications do NOT need to submit minimum documentation requirements.
Renewals: If documentation has not changed since the previous application, applicants do not need to resubmit documents for Leadership: Commitment and support, Action: Antimicrobial stewardship policy, and Action: Antimicrobial use (AU) guidelines for common infections.

Documentation examples (not a complete list) for each element are described below. Other documentation may also qualify.
All documentation must be from within two years of the application deadline, unless otherwise stated.
Details for document requirements are provided with the corresponding core elements in the table below.

Notes 

Do not send protected health information (e.g., patient data such as names, medical record numbers, dates of birth, etc.).
If applicable, please send aggregate data and not line lists of individual cases or interventions (line lists are not useful in the evaluation process).
Please include the time interval of data collection, such as by month or quarter. Most facilities submit data from the most recent year, while a few submit longitudinal data over the lifetime of their antimicrobial stewardship program (ASP) including the most recent year. 
Include definitions for acronyms and non-standard terminology. 
Define metrics if they are not stated in graphs, tables or reports.
If submitting analysis of adherence to clinical guidelines, please also submit the referenced clinical guideline.

Minimum Documentation

Minimum documentation items were chosen based on literature review, current Joint Commission and Centers for Medicare and Medicaid Services standards, and a focus group of ASP pharmacists.

Additional Optional Documentation

Optional upload opportunities are available to provide additional documentation that may help us evaluate your stewardship program. This may include additional documents for accountability, pharmacy expertise, preauthorization interventions, medical use evaluation data, antimicrobial resistance data, antimicrobial stewardship reports shared with stakeholders, or additional types of education such as newsletters.

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