Improvement and implementation science approaches to AMS

In this step, we will explore the emerging importance of behaviour change science to bring about change in prescribing practice. We will explore two key approaches; PPDSA (Prepare, Plan, Do, Study, Adjust) and TACTA (Target Action Context Timeframe Actors). In the next step, we will look at a final approach, TAP (Tailoring Antimicrobial Resistance Programmes).

Implementation science is defined as: the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice and, hence, to improve the quality and effectiveness of health services.

“Implementation fidelity“ is the degree to which a program or healthcare intervention is implemented as intended by the program or intervention developer”. In the context of AMS at national and hospital level this is often suboptimal for a range of reasons.

We often tolerate levels of implementation effectiveness, however putting it into a personal context can prompt us to think about what we should be aspiring to when we are delivering processes of care.

A key paper from 2003 demonstrated the implementation challenge of medical interventions in US hospitals, with patients only having a 55% chance of receiving core standards of care.

Imagine if you found that a loved one had been admitted to hospital with sepsis. Would you be content if they only received this level of care?

There are numerous challenges faced when implementing AMS interventions, however many of these can be overcome by changing people’s behaviours.

AMS and behaviour change

An AMS programme requires complex behaviour change; multiple healthcare providers are required to change multiple behaviours at different time points in the patient care pathway. Change may be required at the individual, team, organisation, and policy levels and behaviour science can be used to inform these changes.

The definitions of behaviour science and behaviour change are outlined below.

Behaviour science: The application and testing of theoretically founded hypotheses through systematic investigation of behaviour and associated factors. Behaviour change: the outcomes of applying behaviour science.

A 2021 paper eloquently describes different categories of methods for behaviour change and their common features as shown below.

Next, we will describe two methods that represent each of these categories: PPDSA and TACTA.

PPDSA Method

Prepare, Plan, Do, Study, Adjust is a quality improvement model that can complement behaviour change techniques. It is essential to:

• Prepare for AMS interventions.
• Make a plan to test a change.
• Carry out the test (do).
• Observe and learn from the consequences (study).
• Make changes to the test (adjust).

Note that many resources will refer to PDSA, omitting the prepare step. The WHO recommends the additional preparation step, which we will include in this course.

Here are some questions to ask when starting to use this model for AMS:

Once the above questions have been answered, the continuous Plan, Do, Study, Adjust (PPDSA) quality-improvement cycle can be followed, as shown below.

The WHO toolkit discusses this method further in chapter 5.4.

AMS interventions can be based on existing structures and built stepwise, involving staff and encouraging champions and reporting of results. It helps to make good use of teamwork and start in small, simple ways.

For example, once the stewardship interventions have been performed in the ‘do’ part of the cycle, measurements can be analysed in the ‘study’ part. Decisions can then be made about whether the interventions should be continued or changed in the ‘adjust’ section. The cycle can then begin again for continuous improvement.

Not all changes create improvements, so measuring progress and making adjustments before testing the plans again is worthwhile.

Click here for an example of a PPDSA Worksheet that could be used for testing changes.

TACTA Behaviour Change Technique (BCT)

The TACTA approach is one simple behavioural approach to articulate a particular change. It is complementary to the PPDSA approach.

The TACTA approach can help identify an exact behaviour that needs to be changed or improved. Behaviours can be specified by Target, Action, Context, Timeframe and Actor. This method can provide specification for your AMS interventions.

Below is an example of applying the TACTA approach to improve the stewardship of antibiotic prophylaxis in a cardiac surgery unit. Because the behaviours are precisely specified, they are easier to measure and can help create a baseline to evaluate the success of interventions to change them.

Translating evidence into practice

In 2008 the BMJ published a model of translating evidence into clinical practice. This model is one type of implementation science approach to changing behaviour. It can be applied to a range of AMS interventions such as improving surgical antibiotic prophylaxis and reduction in central line related infections.

This model is split into four stages:

1. Summarise the evidence
   • Identify interventions associated with improved outcomes.
   • Select interventions with the largest benefit and lowest barriers to use.
   • Convert interventions to behaviours.
2. Identify local barriers to implementation
   • Identify interventions associated with improved outcomes.
   • Select interventions with the largest benefit and lowest barriers to use.
   • Convert interventions to behaviours.
3. Measure performance
   • Select measures (process or outcome).
   • Develop pilot test measures.
   • Measure baseline performance.
4. Ensure all patients receive the intervention (4 E’s)
   • Engage: Explain why the interventions are important.
   • Educate: Share the evidence supporting the interventions.
   • Execute: Design an intervention toolkit targeted at barriers, standardisation, independent checks, reminders and learning from mistakes.
   • Evaluate: Regularly assess for performance measures and unintended consequences.

Methods like these are crucial in speeding up the process for evidence-based practice to be incorporated into routine care.

Finally, there are some excellent courses available on FutureLearn, covering Antimicrobial Stewardship and behaviour change.

Firstly, a massive open online course (MOOC) on utilising AMS to tackle antimicrobial resistance, produced by the University of Dundee and the British Society of Antimicrobial Chemotherapy (BSAC).

Secondly, a course focused on behaviour change, also produced by BSAC, explores how social science and behaviour change techniques can be used within AMS projects.

In our next step, we will look at one more behaviour change strategy: ‘Tailoring Antimicrobial Resistance Programmes (TAP)’.