How to get senior hospital and clinical engagement

Professor Alison Holmes

Professor of Infectious Diseases

Director, NIHR Health Protection Research Unit: HCAI and AMR

Engagement through Organisational change

Holmes, Dinneen, Public Services Review, 8 , 2006 HSJ Feb 2006 Griffiths P, Renz A, Hughes J, Rafferty AM. J Hosp Infect. 2009 Sep;73(1):1-14 http://www.rcpath.org/resources/pdf/bulletinapril08.pdf

E. Lawson, C. Price McKinsey Quarterly 2003: The Psychology of Change Management

Organisational change to drive

AS and HCAI reduction

•  Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management

2009

Engagement through Organisational change

•  Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management

2009

2010

Engagement through Organisational change

Engagement through Organisational change

•  Effective IPC delivery requires expert input operationally and strategically and understanding of interlinking systems and risks in hospital management

2009

2010 2012

UK CMO Report 2013

UK CMO Report 2013

UK CMO Report 2013

‘‘Acute trusts and their boards will need to learn a new language and consider how to strengthen infection prevention and control practice using new methods of organisational and behavioural change to reinforce policy implementation.’’

Some methods to consider:

•  Engage leaders

•  Intelligent design, human factors and decision architecture

•  Better involvement of patients and staff

•  Technology, mHealth and communications

The role of specialty clinical leaders in shaping prescribing practice and behaviour

National Clinical leaders Meeting

London Nov 24th

Antibiotic prescribing in hospitals

34 % NHS inpatients on antibiotics

(47% in independent sector hospitals)

Of those on antibiotics

•  53% for community infection

•  20% for HAI

•  13% surgical prophylaxis

(30% > one day)

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011

Inappropriate use •  Unnecessary exposure

Various studies on inpatient antibiotic prescriptions identify

30-60% inappropriate

Also consider:

•  Rapidity of first dose

•  C. difficile

•  Toxicity and drug interaction

•  IV line usage •  Cost

Davey P, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4)

Willemsen I, Groenhuijzen A, et al Appropriateness of antimicrobial therapy measured by repeated prevalence surveys. Antimicrob Agents Chemo. 2007 Mar;51(3):864-7

Zarb P, Amadeo B, et al. Identification of targets for quality improvement in antimicrobial prescribing: the web- based ESAC Point Prevalence Survey 2009. JAC 2011;66:443–9.

Hecker MT. et al. Arch Intern Med 2003;162:972-978.

������������Policies and guidelines�

•  Guidelines, policy help with decision-making, by providing knowledge and awareness

But, they may not shift attitudes or change practice J Carthey et al BMJ 2011; 343

•  Make optimal antibiotic

prescribing default,

routine practice

•  ‘Mindlines’ not guidelines

Gabbay, Le May. 2004; BMJ 329

Prescribing context

•  Policies and guidelines not enough

•  Collateral impact not tangible at prescriber/patient level •  Behaviour and social science underutilised

•  Qualitative evidence highlights the influence of social norms, attitudes, beliefs, important influence of peer leaders

Charani E et al CID, October 2011;53(7):651–662

Prescribing is a ‘behaviour’

•  Antibiotic prescribing is complex, influenced by many determinants

•  Social sciences and qualitative perspective needed •  Consider human factors and supporting choice architecture

•  Making some small changes

to existing systems to

support optimal prescribing

choices •  Principles of optimal prescribing

need reinforcing/sharing

•  Unwritten rules of prescribing

behaviour need recognising

Unwritten Rules

Unwritten Rules

Unwritten Rules

Conclusion

To influence the antimicrobial prescribing of individual healthcare professionals, interventions need to address these behaviours and use clinical leadership within existing clinical groups to influence practice

•  Professional organisation involvement or research collaboration enhances success

•  Redefine problem as a social problem that can be solved i.e. involving human action and behaviour, not simple technical fix

•  Social process, sense of community •  Systems with network and teams and

sense of ownership

•  Clinicians’ behaviours influenced by trusted peers (Dopson et al. 2003).

•  Leaders with authority to “breathe legitimacy” critical (Hwang and Powell 2005).

Clinical Leadership

Broadening stakeholder involvement

Multidisciplinary approach to antibiotic stewardship has largely included:

•  Microbiologists, ID physicians, Pharmacists •  More recently role of nurses considered, non prescribing

‘knowledge brokers’

•  The Chennai declaration 2012: harnessed leadership of multiple medical specialities at start

Need to broaden stakeholder involvement:

•  Directly involving clinical specialities and their leaders •  Engaging local opinion leaders •  Consider as a key aspect of patient safety and quality clinical care •  Sharing and promoting the principles of optimal prescribing

Principles of optimal prescribing

Start Smart Then Focus

DoH Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) Antimicrobial Stewardship: “START SMART - THEN FOCUS” Guidance for antimicrobial stewardship in hospitals (England) 2011. Cooke FJ, Holmes AH. The missing care bundle: antibiotic prescribing in hospitals. Int J Antimicr Agents. 2007 Pulcini C, Defres S, Aggarwal I, Nathwani D, Davey P. Design of a 'day 3 bundle' to improve the reassessment of inpatient empirical antibiotic prescriptions. JAC . 2008

Focus = Clinical review and antimicrobial decision

making at 48 hrs

after 24 hrs

Impact to be assessed

ARHAI Antimicrobial Prescribing Quality Measures November 2014

•  The critical role of clinical leaders in shaping prescribing practice and behaviour

•  Shared goal of optimising use of antibiotics as intrinsic to quality clinical care, patient safety and public health

•  Ensuring access to effective antimicrobial therapy, minimising negative impact of exposure and sustaining effectiveness

17th International Congress on Infectious Diseases

Hyderabad, March 2-5, 2016

More information at: www.isid.org