Getting started

Antimicrobials have greatly reduced morbidity and mortality due to infection since their discovery. Key benefits of effective AMS programs include improved patient care, more appropriate use of antimicrobials and reduced risk of adverse consequences associated with antimicrobials, including the development of antimicrobial resistance.

AMS is included in the National Safety and Quality Health Service (NSQHS) Standards (specifically the Preventing and Controlling Infections Standard). All health services are required to meet these standards.

To undertake an improvement project, there must be an issue or problem that you aim to improve, for example:

• improving concordance with guidelines (e.g. surgical antibiotic prophylaxis)
• improving documentation of treatment plan (e.g. indication for antimicrobial therapy, stop/review date of therapy, antimicrobial allergies)
• timely intravenous to oral antibiotic switch when clinically safe and appropriate.

At this stage of the project, it is about identifying the problem you aim to improve NOT brainstorming solutions.

When determining the focus of an improvement project, some common errors include:

• Selecting a problem no one is interested in
• Implementing a solution rather than investigating a problem
• Focusing on a process that is currently in transition or unstable, for example, manual to electronic process
• Selecting a problem that is beyond your capability to change or outside your sphere of influence.

All improvement requires change. However, change is not always welcomed or accepted by individuals or teams, even when it is improvement focused. Improvement projects can often struggle to gain momentum if there is considerable resistance from those who will be impacted most by changes.

Assessment of the current unit/ward/facility context is essential to clearly establish the readiness for change. The assessment should investigate the existing culture, communication and team practices, and safety and quality concerns.

If there is an overall lack of enthusiasm and/or a resistance to change, it is vital this is addressed before proceeding further with the improvement project.

For more information see the CEC Safety culture webpage.

Local data will assist in identifying the problem and build the evidence base about why this is an important problem to focus on. Seek guidance from your Clinical Governance Unit, Infectious Diseases, Pharmacy or Infection Control departments for advice.

Alternatively, contact the CEC to identify appropriate sampling numbers and data sources.

Existing data: Examine your health service's existing data relating to antimicrobial prescribing such as the National Antimicrobial Utilisation Surveillance Program (NAUSP), National Antimicrobial Prescribing Survey (NAPS), incidents from ims+, data on resistance organisms and any clinical audits (e.g. 5x5 Antimicrobial Audit).

Baseline: If the existing data is insufficient, consider conducting a baseline audit. You can design your own audit to capture specific data points by using the following fact sheets: AMS Progress and Planning Tool, Key Performance Indicators for Antimicrobial Stewardship , Monitoring and reporting antimicrobial usage, Auditing surgical antibiotic prophylaxis.

Staff and patient stories: gaining information about the experience of the change can provide different insights into program processes, show impact, identify unintended consequences, demonstrate innovation and support the quantitative data.

Gap analysis: The Australian Commission on Safety and Quality in Health Care have indicators which could be used to undertake a gap analysis and identify potential areas for improvement in your AMS Program, refer to Structure indicators for antimicrobial stewardship programs in health service organisations

Literature search: Further information on best practice can be gathered by searching the literature. An example of a literature review analysing evidence from existing research on antimicrobial stewardship interventions and healthcare worker behaviours can be found here: Modifying antibiotic prescribing behaviours.

The improvement project brief is a document that outlines your improvement project. It should include what the problem is, why is it important (to patients, their families, staff and the broader community), how long it will take to do and the approach you will use to achieve an improvement.

A strong improvement project brief should be founded on the supporting data you have collected, should take into consideration how the improvement will be sustained and align with your health service's priorities.

You can use the improvement project brief to help with gaining support for your improvement project. For an example of a project brief, refer to Promoting IV to oral antibiotic switch project charter.

It is strongly recommended that you engage with your Clinical Governance Unit to seek support for, and during, your improvement project. Your Clinical Governance Unit will be able to connect you with local quality improvement advisors/experts.

You may also choose to reach out to colleagues in other health services to find out how they approached their improvement work, including their successes and learnings.

Use your Improvement project brief to gain a project sponsor. The project sponsor is someone who can provide support and guidance to you during the improvement project and has authority to make changes.

They can help with ensuring appropriate resources are provided and help remove barriers when needed. Ideally, your project sponsor is someone who does not work directly on the improvement project but is in a senior position.

The level of seniority of the project sponsor will depend on the scope of your improvement project (for example, Nurse Unit Manager versus an Executive Director). Ideally you should communicate closely with the project sponsor and provide regular updates.

Your project sponsor will be able to provide guidance on where the governance for your improvement project will sit within your health service. This will ensure there is operational responsibility for the improvement project and a channel to report back on how the improvement project is progressing.

For example:

• At unit/ward level: Integrate project reporting with existing departmental or specific Quality Use of Medicines (QUM) review meetings.
• At health service/LHD/SHN level: Integrate project reporting with existing AMS, Medication Safety and/or Drug and Therapeutics Committee (DTC) meetings.

Note this is different from your project team structure. Your project team will consist of members who carry out the project interventions.

• Team leader (essential as the 'voice' of the project, lead meetings and ensure delegation of responsibilities)
• Quality improvement advisor/expert
• People from all areas of the process the improvement project will target, including junior and senior staff -
  • Infection control practitioners
  • Infectious diseases physicians
  • Clinical microbiologists
  • AMS pharmacists
  • Pharmacist, NUM, CNC of targeted ward
  • JMO, medical consultant of targeted specialty/team.
• Consumer representative (or interview/survey consumers)
• Consider inviting colleagues who are likely to challenge your project. They can often raise different perspectives or barriers that you may not have considered.

As the team leader, it is essential to assemble a dedicated team who are also committed to actively supporting the improvement project.

Improvement projects often fail when team members are unable to sustain interest or participation in the improvement project, leaving the team leader to carry the improvement project.

The role of the project team includes:

• evaluating current AMS prescribing or documentation processes
• identifying and enlisting clinical champions
• establishing general goals
• developing, implementing and evaluating improvement strategies
• disseminating results and findings.

Once the project team has been established, it is important to make sure everyone is aligned regarding the problem that the improvement project is targeting and what is in and out of scope.

Without a well-defined scope, improvement projects tend to grow beyond what is achievable, lose focus of the problem, and fail.