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Model for implementation of the basic AS program

How the model for improvement was used in the strategy - Dr Dena van den Berg explains
Do you know, what I’d like to know is what were you trying to accomplish with the Netcare model for improvement? What was the aim? Well, obviously, we were using that model for improvement system and we had to be very clear about what our aim was. And we set our outcome aim as reducing consumption of antibiotics. It was very clear when we looked at our DDDs, we knew that we had an over-utilisation of antibiotics. And so using that measure of– at the end of the day, we can have a lot of activity. We can ward rounds. We can do things.
But we had to make sure that the outcome was reduced consumption of antibiotics and appropriate use of antibiotics without compromising clinical outcomes and clinical care as a part of that. But could you then summarise for me briefly what changes could you make? So we then went to the “low-hanging fruit” and agreed that initially those would be the things that we would do. So we actually standardised those, and we chose the “low-hanging fruit” and agreed that that’s what we would do. And we put in a whole system of measurement to actually support that. We clarified those.
We defined them and made sure that all our pharmacists that were seeing patients in the hospitals and looking and reviewing their prescriptions were doing the same interventions as part of it. So we chose the five “low-hanging fruit” and made sure that those were done. And then finally, what I’d like to know is how did you know that change is an improvement. What measures did you– Well, what we did is we did two things. First of all, we monitored all our prescription data, which is electronic, and we can do a centre for every hospital as well as for the group as a whole. And we tracked that.
We actually did a review of the previous years, prior to implementing this work and then tracked the impact of our interventions on that consumption, using the WHO DDD per 100 bed days data. In addition to that, we measured the individual interventions as outcome measures so that– sorry, as process measures. So the outcome measure was the DDDs, and the consumption and the process measures was each intervention. And then every pharmacist who went, reviewed prescriptions, captured, of the patients that they had seen– what interventions they’d implemented, and what percentage of patients actually had more than four antibiotics or double cover, or had not had a laboratory test done.
And those were all captured into Excel spreadsheets and then collated for the individual hospital and their Net centre. And then you generated monthly reports, using multiple graphs and ranked the hospitals. So initially what we did, using multiple graphs, we actually sent out– in the first month, we sent out the data of every hospital in a multiple graph format. Any hospital that had not submitted their data, we just made red. Any data that looked, you know, not clear, we put in amber. And then everything else was with each hospital’s name. So that added to, you didn’t want to be one of the hospitals that was in red.
And also it gave people an idea of what everybody else was doing, and you could see the results very clearly. And you felt like you were contributing. So we really created a collective success-built model. Everyone felt like they were making a contribution. We were all saving antibiotics for our grandchildren together by doing all of these interventions. But in your case, it was used across 54 hospitals but if any of our learners want to do this in a single hospital, the same principles would apply. Yeah. And in fact, later on we actually used the same methodology in a single hospital using wards– so whatever’s happening. You know, initially, the work was done in intensive care units.
But we soon found that you can’t reduce stewardship antibiotic consumption without extending your programme to the entire hospital. And then we could use the same methodology across all of the wards. And so hospitals were able to say that in this ward– in the surgical ward– this is what’s happening. In the medical ward, that’s where we are. And they could do multiple graphs using surgical ICU, medical ICU, orthopaedic ward, medical ward, and compare what was happening along the way.

In Week 3 you were introduced to PDSA cycles, DDDs, outcome and process measures and in Week 5 Prof Peter Davey explained the Model for Improvement.

This AS programme was implemented using the overall framework along with the Institute for Healthcare Improvement (IHI) Model for improvement within a Breakthrough Collaborative.

Watch this final video with Dr Dena van den Berg as she explains how the model was used.

Their organisational aims and objectives for using the Model for Improvement are attached in the PDF below as a summary of the following questions:

  • What is our organisational objective?
  • What are our drivers for change?
  • What is our measurement plan?

Measurement of the impact of the AS model was conducted for a period of 104 weeks between July 2012 and September 2014.

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Antimicrobial Stewardship: Managing Antibiotic Resistance

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