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Specifying an Implementation Framework for VA Antimicrobial Stewardship Programs

Chou AF, Graber CJ, Jones MM, Zhang Y, Goetz MB, Madaras-Kelly K, Samore M, Glassman PA. Specifying an Implementation Framework for VA Antimicrobial Stewardship Programs. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.

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Objectives: Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programs (ASP) may improve antibiotic usage and patient outcomes, but their implementation remains an organizational challenge for many healthcare systems. Guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify facilitative organizational factors regarding ASP design, development, and implementation. Methods: Using the 2012 VA Healthcare Analysis and Informatics Group Antimicrobial Stewardship (AS) survey, which queried the 130 VA facilities that offered acute care, we classified organizational variables supporting AS activities into three PARiHS domains: (1) Evidence to encompass sources of knowledge; (2) Contexts to translate evidence into practice; and (3) Facilitation to enhance implementation process. We first examined the polychoric correlations among the variables and conducted a series of exploratory factor analyses. We chose question items and identified PARiHS subdomains with conceptually linked factor scales. Cronbach alpha values were calculated. Variables with large uniqueness values were left as single factors. Results: We identified 32 factors, including 8 scales derived from factor analyses. Four factors were within the evidence domain, describing guidelines and clinical pathways. Context domains were further broken down into (I) receptive context; (II) leadership; and (III) evaluation/feedback. Receptive context included items describing resources (5 factors), affiliation/networks (2), formalization of policies/practices (4), decision-making (3), and receptiveness to change (1). There was one factor on leadership and 5 elucidating feedback and evaluation mechanisms. With regard to facilitation, 2 factors described facilitator roles and tasks and 5 captured skills and training. Implications: We mapped survey data onto the PARiHS implementation model to identify factors within each domain. Our subsequent model encompasses mostly mutable factors whose relationships with performance outcomes can be explored to potentially improve patient safety.. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance. Impacts: Successful program implementation has important implications for care provision and patient outcomes. Factors that facilitate ASP identified from this study may be used in empiric assessment to determine their effects on performance and enhance practices that may improve patient safety.

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