In the previous step you were asked to look at the video of the MDT meeting about the outbreak and to jot down notes about whose behaviour needs to change.
First, we’ll think about the prescribers. I would expect that you wrote down the consultant urologists. They were mentioned three times. First of all, they were too busy to come to the initial meetings about the antibiotic policy. Secondly, they were not happy with the proposed antibiotic policy or the national guidelines. And then they failed to attend further meetings about the policy.
The consultant urologists, though weren’t the only prescribers whose behaviour needs to change. You should also have picked up that the urology registrars are not at all helpful in that they tell the pharmacist not to interfere with their prescribing because they know what’s best.
You should have also picked up that the anaesthetists are themselves prescribers and they don’t like the prophylaxis policy. They really don’t like giving gentamicin because they’re worried about kidney injury and they’re the people who, in most hospitals, actually administer the prophylaxis before the operation starts.
In addition to the prescribers, the antimicrobial management team really needed to change their behaviour in two important aspects. The first is that, in the past, they’ve failed to engage the urologists in agreeing the antibiotic policy and they got so fed up with the urologists not meeting to discuss the policy, they just put the policy out and hoped for the best. But they really should have persisted with that and met the urologists because you’re really never going to change someone’s behaviour unless you engage with them.
The second aspect of the antimicrobial management team behaviour that needs to change is that they have just known for a long time that compliance with the policy was poor and they really haven’t tried to change the behaviour. So they said that 18 months ago they knew that compliance with the treatment policy was only 30% and then that one of the team members had talked to a urology consultant who told them that the 30% compliance was acceptable because his patients were doing fine. They also knew that compliance with the prophylaxis policy is poor, probably at around 45 to 60% but the AMT said they couldn’t measure it on a regular basis because they could never find anybody.
And then finally, the AMT admit that they know that most patients are receiving piperacillan tazobactam which is not recommend by the policy. So they have really ignored all of this evidence that the policy is not being followed.
Finally, we come to the medical director. So the medical director is chairing the meeting but he really shows no sign of leadership. He just says he’s disappointed that there’s no surgeon at the meeting without actually proposing to do anything about that. Later, he says he’s concerned about the poor compliance and the lack of engagement with the policy. But ultimately, all he says at the end of the meeting is, we need to sort this out, which doesn’t really give me any confidence that he personally is taking responsibility for sorting this out and making sure that the consultant urologists and anaesthetists do engage with the AMT.
In the previous step, we also asked you to jot down what you thought the barriers to change were in this hospital, and to really think about how that relates to your hospital. So what I think you’ve seen in the video of the MDT meeting is examples of barriers to change which have been found to be common across really all hospitals. So this slide shows some data from work by Esmita Charani. And you’ll be hearing more from her about her research. But this particular paper got data from interviews in several hospitals and hospital teams and what they found that emerged were three recurring issues around barriers to change.
So the first they call decision-making autonomy, which is that the team tend to defer to the most senior member of the team and they’re not going to challenge a consultant surgeon or a consultant anaesthetist. The second was that there was limitation of local evidence-based policies, or perceived limitation. So there’s a feeling that my patients are different. The policy is just about average patients. My patients aren’t average. And then finally, the third one is that there is a hierarchy and that junior doctors won’t change things if they perceive that their senior doctors, consultants, or registrars have actually asked them to prescribe something else.
But as well as those three things, what Esmita Charani’s work shows is that there’s a cross cutting issue of etiquette that in general, doctors do not like to be seen to criticise their colleagues. So if one doctor changes another doctor’s prescribing, that’s perceived as not being collegial practice and people don’t want to be seen to be criticising one another.