Antimicrobial Stewardship

Behaviour change

Key points
  • Existing organisational culture and hierarchy play an important role in determining prescribing behaviours.
  • The success or failure of a quality improvement initiative can be strongly influenced by local key opinion leaders.
  • Early in the planning phase, consideration should be given to incorporating behaviour change techniques into the project design to maximise the possibility of the intervention succeeding.
Introduction

The success of AMS interventions hinges on changing clinician behaviour. Successful AMS programs consider the various factors that impact on human behaviour and specifically on the decision-making that influences how a prescription is generated and then managed over time. Staff working in AMS programs need also need to be able to anticipate the ways in which staff and patients may react, either positively or negatively, to a proposed change in practice. 

What drives behaviour?

Understanding the key principles of behaviour change theory can help AMS teams to successfully engage with clinical staff. Susan Michie and colleagues have characterised the drivers of behaviour in the COM-B model, where capability, opportunity and motivation impact on behaviour. Consider whether staff and patients have the:
  • Capability and knowledge: education is provided so staff and patients know what to do and understand what is expected.
  • Motivation to make the change: this will be determined by their attitude and feelings about the change, whether it is important to them and whether they think other people (their peers and leaders) care. 
  • Opportunity to make positive changes: minimise barriers by streamlining procedures, improving access to tools and the right medications, and allowing adequate time to complete required tasks.  
Organisational culture 

Hierarchy can be an important influence on the ability to change prescriber behaviour. In some settings, team members may be reluctant to question or change the decisions of others, especially if this contravenes etiquette and if the original prescriber is seen to be more experienced or more senior. It can take work to try to breakdown this barrier, and in some cultures the hierarchy can be much more entrenched than in others. 

It can be helpful to shift the organisational culture to one of teamwork and collaboration. Together we are working to ensure “our” patients receive the best care. The use of guidelines can be promoted as a way to promote excellence in care. A culture that values research and learning can positively impact upon this, with an explicit intention to provide high quality evidence-based care. Ideally, the executive and clinical leaders help promote a culture that supports quality improvement.

Clearly the idea of transparency and a willingness to reflect on opportunities for improvement can be a difficult change to embrace in some settings. It may take time to build a non-threatening environment in which to discuss cases, reflect, and be open to learning and changing embedded behaviours. 

Stakeholder engagement

The chain of events involved in diagnosing and treating an infection is complex. Meeting with staff and patients to understand current practices and hospital culture is an important early step in identifying the potential barriers to change and how they can either be overcome or accepted as a limitation of the intervention.

Interpreting evidence or guideline-based information requires human judgement and clinician experience strongly influences decision-making in healthcare. Interventions, therefore, need to be designed in a way that is inclusive, engaging with clinicians at all career stages and across all disciplines of medicine. 

Within an organisation, identify key opinion leaders who see the value of AMS practices and can facilitate staff acceptance of your initiatives. Ideally, these leaders will come from a variety of clinical backgrounds (nursing, medical, pharmacy, etc.) and be able to offer insights into the key drivers influencing local prescribing behaviour. 

AMS champions who come from a non-infectious diseases background are important because they know how to incentivise behaviour change in their specialist area and promote adherence to changes in practice. Their insights into local hierarchies can be invaluable and they are also in a position to influence cultural norms within the workplace. They should be encouraged to lead local interventions and contribute to all stages of the intervention. 
 
Baseline information

In addition to consulting key staff members, it can be helpful to collect some objective baseline data to substantiate the state of current practice. Direct observation of staff behaviours can confirm that there is an issue with the prevailing system or culture, while an audit can provide hard evidence that practice improvements are needed.

At this stage it can be useful to begin discussions with regular staff to understand the complexities of their workflow and determine the factors that are influencing current practice. As much as possible, all relevant healthcare practitioners should be included in this process to ensure the needs of the multidisciplinary team are considered. Building relationships with staff who are regularly engaged in patient contact will help to generate support for the project and the AMS service in general, as well as providing an opportunity to guide behaviour towards the desired outcome.

Designing an intervention

After this engagement period, consider the change(s) that could be made and that will result in practice improvement. Within the context of the local culture, look for the simplest solution that addresses the problem and can be scaled-up to become self-sustainable. Ensure new interventions integrate smoothly into the decision architecture, workflows and pathways of the clinical team. It should be easy to do the right thing.

A proposed change in practice is more likely to be well received by clinicians if the treating unit is actively involved in choosing the intervention and the decision-making process overall. When engaging in goal-setting with clinical staff, ask “What are we trying to accomplish?” and link the goal to important organisational or patient outcomes.

Ideally, the proposed changes should adhere to the principles of the SMART acronym and be:
Specific Examples
What is the target behaviour and what exactly do you want to change about it? Ensure the audience understands what they are being asked to change and why. Does it involve one component (e.g., correct dose) or multiple components (e.g., right drug, dose, route, duration, etc.)?
Measurable Examples
Set a specific target for the behaviour Avoid vague statements such as: “Increase use of drug X.” “Improve adherence to guidelines.”
Instead, consider a clear goal: “In accordance with guidelines, we aim to prescribe cefazolin 2g IV within 60 minutes prior to the incision as first-line therapy for surgical prophylaxis for the following operations…” “We aim to achieve guideline-concordant prescribing >95% of the time.”
Achievable Examples
Focus on small incremental gains that are significant but seem achievable to staff Obtaining a few “quick wins” will develop enthusiasm for the project and build momentum to make larger changes at a later date. “Current practice is correct 70% of the time. We will report on progress monthly and aim for 80% next month.”
Relevant Examples
Participants should be actively involved in setting the agreed targets and it should be meaningful to them Staff should agree on the who, when, where and how of the intervention. The lines of accountability should be clear.
Time-limited Examples
A specific target is best “The timeframe to achieve our goal of 95% concordance is 3 months.”

Staff should know exactly which behaviour they need to change or what positive outcome they need to achieve, how to achieve it, the precise measure of success and the time period in which they must make the change. 



In isolation, interventions such as creating new guidelines or performing audit/feedback cycles are unlikely to drive effective change. However, when included as part of a broader plan and combined with goal setting, education and action planning, they form a very effective strategy that is highly likely to influence clinician behaviour.



Implementation and monitoring



Communication is key to implementing a new campaign. It can often be helpful to nominate a “go live” date so that the stakeholders can be fully informed in the weeks leading up to the launch and feel properly prepared. They know what is expected of them and when monitoring is going to begin. New initiatives can be derailed if staff feel that they have not been consulted or informed. It is important that everyone feels like part of the team and is allowed to have some ownership of the issue.



Monitoring can be undertaken by an external auditor or the AMS team with the goal of demonstrating positive behaviour changes and improvements in antimicrobial use. Alternatively, the AMS service can establish a method that allows individuals or teams to self-monitor their prescribing and record the outcomes of their behaviour, as part of an overarching strategy. Such monitoring may take the form of manual, paper-based audits or incorporate information technology solutions.



Evaluation and feedback



Feedback should be timely, non-punitive, customised and actionable. Where possible, a face-to-face session should be arranged, supplemented with written material. Methods of feedback can include educational outreach interventions such as academic detailing, where a trained AMS team member meets with clinicians to provide them with information with the intent of changing their practice. This can be achieved through one-on-one or group feedback sessions. 



Performance feedback should be accompanied by a comparison with a performance target and strategies to improve performance. A feedback system based on peer group comparisons provides motivation to improve practice. If data are available, staff can see how they compare to other clinicians, wards, clinical units or healthcare facilities. Reports that focus on “our ward” or “our unit” can again build a sense of ownership.



The efforts of the team should be acknowledged and any positive changes highlighted and rewarded. In cases where performance has fallen short of expectations, allowing staff to explain why the plan is not working and offer their own suggestions for improvements can be extremely valuable in fine-tuning the campaign. A new action plan, such as initiating a Plan-Do-Study-Act cycle, can then be initiated. 

Implementing antimicrobial stewardship

Policy drivers for AMS