Antibiotic Stewardship

30/30 Education Session - 30 minutes

1301 - Gap Analysis 101: Utilizing the New Joint Commission Antimicrobial Stewardship Standard to Develop a Gap Analysis Tool

Wednesday, June 14
3:00 PM - 3:30 PM
Location: Oregon Convention Center, E 141-144

Challenged with developing a gap analysis, where does the infection preventionist begin? This presentation will provide the participant with tools to develop and perform a gap analysis and identify intervention opportunities. In November 2015, The Joint Commission proposed accreditation standards for antimicrobial stewardship. Utilizing the proposed standards, all BJC HealthCare inpatient hospitals were asked to complete a self-assessment survey. Surveys were completed by hospital pharmacists and antimicrobial stewardship physicians, where available. Surveys were completed between March and April 2016. The survey included 85 questions across 12 antimicrobial stewardship practice domains. Initial analysis by BJC HealthCare identified practice variation across the 12 hospitals. Survey questions were mapped to the CDC’s Core Elements for Antimicrobial Stewardship Program standards to assess practice gaps. Standards for compliance with a CDC Core Element were established. Once practice gaps were identified, analysis was completed to identify who would be responsible for addressing the gap. Owners included the local hospital, the healthcare system, or a partnership between local and system resources. These categories helped identify accountable parties and prioritize resource allocation to meet the new antimicrobial standard. Results of the gap analysis were shared with a multidisciplinary group of antimicrobial stewardship stakeholders in July 2016. Completion of this process allowed all hospitals to identify and address antimicrobial stewardship practice gaps prior to regulatory mandates on January 1, 2017.

Learning Objectives:

Sponsored By: 

Jeanne Zack

Quality Patient Care Consultant Center for Clinical Excellence
BJC HealthCare
Saint Charles, Missouri

Jeanne Zack is currently a quality patient care consultant in the Center for Clinical Excellence at BJC HealthCare and serves as adjunct nursing faculty at Webster University. Jeanne’s current focus is antimicrobial stewardship for a 12-inpatient facility. Previous positions include critical care and home care nurse, infection prevention specialist, and manager of infection prevention and occupational health. She’s a graduate of Barnes Hospital School of Nursing (1980), Maryville University (1995), and University of Missouri, St. Louis, with a PhD in nursing (2008). In 2013, Jeanne was awarded Nurse of the Year from the March of Dimes. Jeanne has received Distinguished Alumni Awards and was the 2011 recipient of the SHEA’s Advance Infection Preventionist Award. She has consulted and spoken nationally and internationally about infection prevention initiatives. Her work in reducing healthcare-associated infections using educational interventions has been replicated in Thailand.


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Irena L. Kenneley

Associate Professor/Faculty Development Director
Case Western Reserve UniversityFrances Payne Bolton School of Nursing
Cleveland, Ohio

Irena L. Kenneley, PhD, RN, CNE, CIC, FAPIC is a researcher and associate professor of nursing at the Frances Payne Bolton School of Nursing, Case Western Reserve University.

She teaches microbiology, infection control and public health to undergraduate and graduate nursing students. Dr. Kenneley has 30 years' experience across the continuum of health care delivery and as an infection preventionist.

Dr. Kenneley has worked in numerous areas within nursing and infection control including critical care, risk management and performance improvement. She has expertise in infection prevention, microbiology, immunology, including home health care and pandemic planning.

Dr. Kenneley is currently is one of APICs Board of Directors. She is the author of My Bugaboo in Prevention Strategist.

Dr. Kenneley graduated from Lake Erie College in Painesville, Ohio with a Bachelor in Science degree. She received her MSN in Public Health Nursing, and PhD from Case Western University, Cleveland, Ohio.


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1301 - Gap Analysis 101: Utilizing the New Joint Commission Antimicrobial Stewardship Standard to Develop a Gap Analysis Tool

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