Molly McAllister, DVM, MPH
Banfield Pet Hospital, Portland, Oregon
Welcome to VET Report Vitals, a column focused on the results of the groundbreaking Banfield Veterinary Emerging Topics (VET) Report, “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.” This report, a collaboration between the NAVC and Banfield Pet Hospital, focuses on a critical topic: antimicrobial resistance (AMR). It promotes prudent antimicrobial use among companion animal practitioners by contributing a baseline of antimicrobial usage data to the discussion on how to improve concordance with published guidelines. This article examines the issue of AMR within the larger One Health context and proposes a method by which to change behavior among hospital teams and drive quality improvement within the veterinary profession.
THE MODEL FOR IMPROVEMENT
Addressing AMR in a veterinary clinic is a quality improvement challenge that can be approached by using structured methods for success. Quality improvement developed as a science in the 1950s. It began as a tool in the manufacturing industry, and its applicability to a variety of other situations, including healthcare, was quickly recognized. The Model for Improvement, developed by Associates in Process Improvement, guides application of key concepts of quality improvement to business challenges of many types.
In alignment with the Model for Improvement, a journey of quality improvement begins by asking 3 crucial questions:1
1. AIM: What are we trying to accomplish?
To define the aim, the user must explicitly define what is to be accomplished and the timeframe in which it is to be achieved: for example, “Improve concordance with first-line drug recommendations for urinary tract infections [UTIs] by 50% over a 6-month period.”
2. MEASURE: How will we know that a change is an improvement?
Objective measures are used to determine the point at which the goal has been reached. This requires data for baseline measurement and results to compare against. Many data sources can be used to measure antimicrobial guideline concordance, but all must be assessed for validity and accuracy to ensure appropriate interpretation. Examples include medical record reviews, logs of antimicrobial dispensing practices, case response logs, doctor surveys, or a combination of data. A sample objective measure is “Track UTI diagnoses and resulting prescriptions on a clipboard in the pharmacy. Assess percentage of cases that received recommended first-line antimicrobial.”
3. CHANGE: What changes can we make that will result in improvement?
Finally, a plan is created by identifying barriers to achieving the desired goal and determining potential strategies to address them. Brainstorming applicable goals, barriers, and strategies should involve all members of the veterinary team and might also include clients, pharmaceutical representatives, and local professional organizations, among other stakeholders. An example is “Relocate first-line antimicrobials in the pharmacy so that they are easier to find. Ensure that pricing of antimicrobial drugs supports use of recommended first-line drugs.”
HUMAN FACTOR ENGINEERING AND NORMALIZATION OF DEVIANCE
Not all changes to a system have equal likelihood of driving improvement. Experts in human factors engineering—a discipline that combines engineering and human psychology—have demonstrated that people make mistakes for many reasons: lack of knowledge or experience, misinterpretation or misuse of rules and processes, and lack of necessary skills to accomplish a task.2 Human factors engineering involves identifying and accounting for factors that influence the human ability to perform a function, including environmental conditions (eg, temperature, light level, noise), stress levels, leadership, culture, interruptions, and the need to cut corners or multitask to keep pace with expectations.
Brainstorming applicable goals, barriers, and strategies should involve all members of the veterinary team and might also include clients, pharmaceutical representatives, and local professional organizations, among other stakeholders.
Also important to consider is normalization of deviance: the gradual acceptance of actions that deviate from standards of practice until such actions become the norm.3 For antimicrobial use, this may include straying from the guidelines, ignoring risk factors, or not educating clients about preventive strategies. Any healthcare practitioner can deviate from the norm. In the case of inexperienced practitioners, it may be due to a lack of knowledge or understanding of why a rule is in place. For experienced practitioners, it may stem from a belief that personal experience is more trustworthy than the standard. Addressing normalization of deviance requires a culture that supports appropriate behaviors and accountability and ensures that communication about standards of practice is consistent and effective.
When identifying potential changes for improvement, different strategies have different reliability levels:2
- Most reliable:
- Functions or physical stops that prevent incorrect actions
- Computerized automation
- Human/machine redundancy
- Somewhat reliable:
- Pauses in a process to recheck details and steps
- Standardization of equipment and supplies
- Self-check or double-check
- Least reliable:
- Education and training
- Rules, policies, and procedures
Fundamental changes that have a higher likelihood of success include those that affect how work is done, produce observable positive differences, and have a lasting impact. Such changes result from design/redesign of a process or system or those that fundamentally change how a system works and what is done to drive it forward. Examples include applying standardization, streamlining choices, and changing the order of tasks; implementing cross-training; and soliciting feedback from customers or employees.1
Any change intended to influence medical prescribing practices requires buy-in from clinicians and team members. As such, large-scale, abrupt changes may not be readily accepted or adopted and are often operationally unfeasible or risky. Small, incremental changes can be more acceptable and allow for better assessment of their true effects in the complex environment of a healthcare facility. The implementation of incremental changes is supported by the “plan, do, study, act” (PDSA) cycle, a tool of the Model for Improvement. The PDSA cycle is a recognized method for quality improvement projects that requires thoughtful planning and implementation (“do”) of a step intended to move toward a goal; study of results; and actions to ensure continual progress toward the improvement desired.
PUTTING THE MODEL INTO ACTION
Once a clear goal and a model to achieve it are identified, the next step is to identify changes that are believed to lead to meaningful progress. Our goal is to achieve voluntary adjustment of usage patterns among veterinarians to improve concordance with existing guidelines.
To begin this process, we must understand the perceived barriers to appropriate antimicrobial use. An American Veterinary Medical Association survey revealed that barriers to antimicrobial use in concordance with guidelines included lack of awareness of guidelines.4 Other surveys indicate that pressure to dispense antimicrobials to satisfy client expectations influences antimicrobial use, as does the cost of culture and susceptibility testing.4,5 Finally, intrinsic factors, such as personal preference, and extrinsic factors, such as perceived compliance by client and willingness/ability of the client to pay, may influence decision-making about antimicrobial use.5 Additional barriers to alignment that might be considered include availability of first-line antimicrobials, dosing regimens, and owner compliance.
One proposed change might be to improve visibility to prescriptions and outcomes in a clinic. “Plan” could entail tracking of antimicrobial prescriptions and outcomes across cases. Implementation (the “do” step) might include a checklist where the drug and outcome are recorded and reviewed weekly. After an appropriate amount of time, results would be evaluated (the “study” step) and potential adjustments to make the process more effective would be assessed. On the basis of that assessment, the “act” step would involve refinement of the goal and planning for subsequent cycles. Another cycle would be started with adjustments for improvement, allowing each subsequent assessment to guide the types of improvements needed to improve guideline concordance.
Banfield has always been dedicated to using its extensive data to provide insights to the profession on topics that can improve veterinary care for pets. The first annual Banfield Veterinary Emerging Topics (VET) Report, supported by the collaborative educational efforts of the NAVC, focuses on a critical topic: antimicrobial resistance. It is titled “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.”
“We are proud to team up with the NAVC on the 2017 VET Report to raise awareness about the critical topic of antimicrobial resistance in companion animal practice and how veterinarians can address it in their own practices,” said Dr. Karen Faunt, Vice President of Medical Quality Advancement at Banfield Pet Hospital.
The full report is available at Banfield.com/VETReport or VetFolio.com/VETReport.
Once potential areas for improvement are identified, it is time to implement a PDSA cycle (Box 1).
This method of incremental change allows for operational and behavioral acceptance by minimizing major disruption, while measurement and assessment ensure that the right changes are being made. From a healthcare perspective, these safeguards help ensure patient safety and quality of care by confirming that a change has the intended effect before widespread implementation.
BOX 1. Sample “Plan, Do, Study, Act” Cycle
PLAN: Consider the goal, what you need to do to get there, and what to measure to ensure it is met.
- “Achieve 80% compliance with first-line antibiotic recommendations for UTIs within 6 months of implementing changes by daily tracking of prescriptions and outcome for each UTI case seen.”
DO: Implement the plan. Focus on small, incremental alterations rather than widespread change.
- “Add clipboard to pharmacy and have staff track all UTI diagnoses and associated prescriptions, including client, pet, drug, duration, dose, frequency, and outcome. Review list in weekly team meeting.”
STUDY: Work to understand the outcomes of the change. Sometimes unintended results have a larger impact than intended results. By understanding the consequences, you may adjust the plan to better achieve your stated goals.
- “Assess process with staff after 3 months for feasibility and efficacy. Assess outcomes after 6 months and review with veterinarians to determine next steps.”
ACT: Finally, make adjustments that were indicated in the “study” phase, and then repeat the cycle. Regularly analyze the results of each new cycle to inform the next step and ensure continual progress toward the goal.1
- “Based on staff input, outcomes will be recorded after 2 weeks following call back with client and discussing with doctor. Switch from notes to checklist to improve efficiency.”
- “Ensure that first-line antimicrobials are always stocked in the hospital by adding them as a standing item to the weekly order list.”
CLINICAL BOTTOM LINE
Addressing an issue such as AMR may seem daunting, but progress can be made if the solution is broken into small, manageable goals to improve medical quality. The science of quality improvement, specifically the Model for Improvement, provides simple yet effective processes and tools for achieving this progress. Through the combined efforts and brainpower of all members of the veterinary team, a clinic can address nearly any problem by following the steps outlined in this article.
- Langley GJ, Moen R, Nolan KM, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: John Wiley & Sons; 2009.
- The Joint Commission. Human factors analysis in patient safety systems. The Source 2015;13:1-10.
- Banja J. The normalization of deviance in healthcare delivery. Bus Horiz 2010;53:139.
- American Veterinary Medical Association Task Force for Antimicrobial Stewardship in Companion Animal Practice. Understanding companion animal practitioners’ attitudes toward antimicrobial stewardship. JAVMA 2015;247(8):883-884.
- Mateus AL, Brodbelt DC, Barber N, et al. Qualitative study of factors associated with antimicrobial usage in seven small animal veterinary practices in the UK. Prev Vet Med 2014;117(1):68-78.