(Management Case Study) Structural Change to a Community Hospital’s Antimicrobial Stewardship Committee to Optimize Physician Engagement and Hospital Goal Achievement

Purpose: Ongoing efforts are required to support and develop quality antimicrobial stewardship (AS) programs based on the Centers for Disease Control and Prevention’s core elements and regulatory body requirements. During preparation for a statewide AS collaborative and anticipated regulatory requirements in 2017, hospital AS leaders determined the need for more robust interdisciplinary engagement outside of the pharmacy department to meet requirements and further advance efforts. This case describes how the AS Committee optimized its structure and operations to create a sustained hospital culture promoting antimicrobial stewardship efforts.

Methods: Physician and pharmacist AS leaders analyzed the potential benefits of transitioning the AS Committee from under the organization of the Pharmacy and Therapeutics Committee to the newly formed Clinical Efficiency Program (CEP). CEP is a physician led interdisciplinary program that allows for incentive-based compensation for creating hospital savings and efficiencies in care delivery processes when pre-determined quality outcomes and individual participation criteria are met. Once criteria are met, participating physicians share in the overall cost savings. AS became a CEP sub-committee after it was determined that its structure could be more effective for targeting and achieving quality improvement outcomes. Physician and pharmacist leaders collaborated with the AS Committee to determine annual goals for improving antibiotic usage based on national guidelines, new scientific literature, provider antibiotic usage, or local antibiotic resistance trends. Goals were required to be specific, measurable, achievable, relevant, and time bound (SMART) yet still broad enough to allow all inpatient providers participating in CEP to improve their antibiotic utilization. The AS pharmacist leader worked with the Quality Department and an independent consultant group to determine fair market value cost savings for annual goals based on tiered levels of improvement. Throughout each year, the plan, do, check, and act (PDCA) cycle was implemented as part of the AS Committee’s tracking and reporting process at bimonthly meetings to help with achieving the targeted goal(s).

Results: To date, the AS Committee has completed CEP participation from 2016 through 2022 and has met 7 of 8 annual goals. CEP participation led to increased provider engagement across different specialties in multiple settings as well as improvements in antibiotic usage leading to cost savings shared between the hospital and participating inpatient physicians. Completed SMART goals have targeted order set utilization for specific infections in addition to decreasing vancomycin, carbapenem, and anti-Pseudomonal beta-lactam antibiotic usage defined as days of therapy per 1000 patient days. Initial ideas for interventions were determined prior to each year but were re-evaluated through the PDCA cycle for improvements in meeting goals. Pharmacist-led physician engagement and interventions included 1) various forms of education for healthcare providers, 2) creation and updates to antibiotic order sets, 3) maximization of information technology through the electronic medical record and the clinical pharmacy surveillance platform, 4) addition of new laboratory technology, and 4) repetition of certain goals for continued improvements. Multiple strategies were utilized to update providers on the current status of CEP goals as well as their individual performance through the utilization of report cards, password protected website, and annual CEP meetings.

Conclusion: Structural and operational changes to the AS Committee led to improvements in physician engagement in addition to creating and achieving most annual AS hospital goals over a 7 year period.