Antimicrobial Stewardship Center of Excellence Application & Designation Terms & Conditions

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CDC CORE ELEMENT: Reporting

Provide evidence as to how your hospital currently shares facility and/or individual prescriber-specific reports on antibiotic use with prescribers, including personalized reports on prescribing patterns and opportunities for improvement to key stakeholders.
All reports should be facility-specific (not just accumulated data from an organization).

Possible Supporting Documentation

* Evidence of ASP reporting with a targeted performance for intervention
* Unit-specific reports for display and education
* Direct reports of tracked ASP measures to medical staff
* Institution-specific example reports on medication use evaluations (templates, past reports, etc.)
* Outline of reporting structure

CDC CORE ELEMENT: Education

Provide examples that reflect well-established and ongoing education efforts with different healthcare groups (clinicians, prescribers, pharmacists, nursing, etc.). Examples should be within the last 3 years.

Possible Supporting Documentation (Provide up to three examples).

Presentation given within the past 12 months to physicians and/or pharmacists and/or nurses and/or other relevant staff relating to antibiotic usage/optimization (if a PowerPoint presentation, please convert to a document showing 2-3 slides per page)
Patient education materials given to patients/caregivers regarding antimicrobials
Information provided to patients/caregivers on discharge when discharged to complete an antibiotic regimen
Educational material developed in collaboration with nursing representative
Communication provided to patients/caregivers as part of an ongoing patient education effort (e.g., newsletter)
Post-test or knowledge assessment.

EDUCATION Supporting Documentation

EDUCATION Additional Supporting Documentation

Optional: Provide documentation of involvement in educational efforts regarding antimicrobial usage/stewardship on a national level (e.g., involvement in an organization or committee focused on provider education).

Part III: Optional
Provide any additional information on regional or national stewardship collaborations, publications, and presentation.

Possible Supporting Documentation

List of stewardship-related publications within the last 3 years (citations only).
Description of stewardship collaborations your hospital has participated in the last 3 years (i.e., how your hospital engages in ongoing, formal collaboration beyond your facility to advance antibiotic stewardship, whether informal or on an as-needed basis).
List of stewardship regional and national presentations within the last 3 years.
List of stewardship-related research grants within the last 3 years.

REGIONAL or NATIONAL Supporting Documentation

Part IV: Optional
Include additional documents that you feel will be helpful for the review panel in assessing your application.

For internal purpose only

Was there a previous application from this hospital for the CoE designation?

Has the hospital ever been awarded the CoE designation?

Terms & Conditions

By signing below, I acknowledge and agree that I am authorized as a representative of the Hospital submitting this application to accept the following terms and conditions, on behalf of the Hospital, for participation in the Antimicrobial Stewardship Centers of Excellence ("Program"):

Participation and designation by IDSA as an “Antimicrobial Stewardship Center of Excellence” is subject to Hospital’s compliance with all applicable laws and IDSA policies, including specifically those policies related to the Program.

IDSA is the sole owner of all rights, title, and interest in and to IDSA’s name and trademarks, including the IDSA “Antimicrobial Stewardship Center of Excellence” designation, for which a limited, revocable, non-assignable license will be granted to Hospital for use, only upon the prior review and approval of IDSA, and subject to the terms and conditions of the Program.

The Hospital shall pay a non-refundable license fee of five thousand dollars ($5,000.00) with each approved initial or renewal application for participation in the Program.

The limited license herein and related fee will be valid for two (2) years starting with the date listed on the Program designation letter and certificate provided by IDSA and will expire at the end of the two (2) year period. Hospital’s use of the limited license must cease following expiration or termination of Hospital’s participation in the Program.

IDSA will list the Hospital’s name on its public website list of Antimicrobial Stewardship Centers of Excellence.

Neither IDSA nor the Hospital may disclose any Confidential Information of the other that was acquired in the course of Hospital’s application to or participation in the Program, except as permitted by the other party or under compulsion of law. "Confidential Information" means any information that is not generally available to the public.

Any notices or communications required for the license shall be in writing via electronic mail to the contact persons designated by IDSA and Hospital and shall become effective upon receipt unless the recipient responds otherwise.

IDSA may terminate Hospital’s participation in the Program for the Hospital’s breach of 1) these Terms and Conditions; or 2) any other applicable requirements or obligations under the Program upon written notice and Hospital’s failure to cure such breach within ten (10) days of the written notice.

Hospital Name

Name of Hospital representative

Title

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