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Effective Stewardship Leadership

Effective Stewardship Leadership. Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCP Chair, Infectious Disease Division Summa Health System, Akron, Ohio; Professor of Internal Medicine, Chair ID Section Northeast Ohio Medical University Rootstown, Ohio. LEARNING OBJECTIVES.

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Effective Stewardship Leadership

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  1. Effective Stewardship Leadership Thomas M File Jr. MD, MSc, MACP, FIDSA, FCCP Chair, Infectious Disease Division Summa Health System, Akron, Ohio; Professor of Internal Medicine, Chair ID Section Northeast Ohio Medical University Rootstown, Ohio

  2. LEARNING OBJECTIVES At the end of this lecture, the learner will be able to: • Identify roles for leaders of Antimicrobial Stewardship Programs (ASP) • Describe key skills and practices of effective leaders. • Discuss ways to apply leadership skills to improve the antimicrobial stewardship team.

  3. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature ReviewFrontiers in Ped. 2018; 12 Oct doi: 10.3389/fped.2018 “The need for a strong leadership in antimicrobial stewardship programs is often mentioned but rarely defined.”

  4. “True leaders are the first to admit they don’t know everything and that they need help.” Bill Byrd

  5. What is a Leader? Mind Tools Ltd Variety of images: • A political leader pursuing a personal cause • An explorer, cutting a path through a jungle for the rest of a group • A company executive developing a strategy to “beat” the competition

  6. Leadership From “free encyclopedia” Leadership is practical skill regarding the ability of an individual or organization to “lead” or guide other individuals, teams, or entire organizations .

  7. LEADERS ESTABLISH ANTIMICROBIAL STEWARDSHIP AS AN • ORGANIZATIONAL PRIORITY • As emphasized by TJC standards and IDSA guidelines, strong leadership commitment is critical to the success of an ASP. • Achieved via identifying healthcare leaders and promoting ASP as a patient care, safety, and quality issue. • The physician and pharmacist co-leading ASP requires strong leadership skills, including trust, confidence, and willingness to stand on principles. Simply appointing a person to lead ASP does not qualify the individual as a leader. Clin Infect Dis. 2017

  8. Attributes of an Effective Leader Ostrowsky B et al. Clin Infect Dis. 2018; DOI: 10.1093/cid/cix1093

  9. Leadership Expertise of ID Physicians of ASP Ostrowsky B et al. Clin Infect Dis. 2018; DOI: 10.1093/cid/cix1093

  10. The ASP (Co)Director needs to be able to: • engage • motivate • inspire • influence others • not fear confrontation.

  11. Qualities of a Good Leader Multiple sources Knowledgeable Principled Respectful/ Respected Communicates Positive/Motivational Displays a good example

  12. Habits of highly effective people Covey SR. The 7 Habits Of Highly Effective People. Free Press, 1989. NY. Independence • Be Proactive • Don’t wait for problem to occur before taking action • Begin with End in Mind • Act on Principle; Know your mission statement • How do you want to be remembered • Put First Things First What is important what is urgent • Important and urgent • Important and not Urgent • Not important and Not Urgent

  13. Antimicrobial Stewardship • Definition • “An ongoing effort…to optimize antimicrobial use in order to improve patient outcomes, ensure cost-effective therapy, and reduce adverse sequelae of antimicrobial use (including antimicrobial resistance)” Dellit T, et al. Clin Infect Dis. 2007;44:159-177.

  14. ….refers to selecting the most obtainable targets rather than confronting more complicated management issues. • intravenous-to-oral conversions, • batching of intravenous antimicrobials, • Therapeutic substitutions, • formulary restriction. • ….require fewer resources and less effort than other ASP activities; are applicable to a variety of healthcare settings, including limited resource hospitals • … have demonstrated significant financial savings. • ($832 590 at OSU) Clin Infect Dis. 2012; 55: 587-92

  15. “A genuine leader is not a searcher for consensus but a molder of consensus.” Martin Luther King Jr

  16. Habits of highly effective people Covey SR. The 7 Habits Of Highly Effective People. Free Press, 1989. NY Interdependence • Think Win-Win • Value consensus, not if only one person has gotten their way • Seek First to Understand, then to be understood • Use empathetic listening to genuinely understand a person • “You can’t learn if you are always talking” (TV add) • Synergize • Combine strength through teamwork • Work from the center of your influence, then expand; don’t sit and wait in reactive mode • Improvement • Sharpen the Saw. • Balance your resources, energy, and health to create sustainable, effective lifestyle

  17. Hospital Antimicrobial Stewardship: Implementation • Core Members: • Primary: ID Physician and Clinical Pharmacists with ID training • Collaborative: Clinical microbiologist; Infection control professional; Hospital epidemiologist; Administration; Quality Assurance Dellit T, et al. Clin Infect Dis. 2007;44:159-177

  18. Antimicrobial Stewardship Teams Multidisciplinary Team Approach to Optimizing Clinical Outcomes HospitalAdministrator HospitalEpidemiologist InfectiousDiseases Division InfectionControl Director, OutcomesResearch ASP Directors• ID PharmD• ID Physician MedicalInformationSystems Chairman,P&TCommittee Partners in OptimizingAntimicrobial Use Suchas Pulmonologistsand Surgeons ClinicalPharmacySpecialists MicrobiologyLaboratory DecentralizedPharmacySpecialist ASP = Antimicrobial Stewardship Program, ID = infectious disease, P&T = Pharmacy and Therapeutics.Dellit TH et al. Clin Infect Dis. 2007;44:159-177 and Fishman N. Am J Med. 2006;119:S53-S61.

  19. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature ReviewFrontiers in Ped. 2018; 12 Oct doi: 10.3389/fped.2018 • The need for a strong leadership in ASM programs is often mentioned but rarely defined. • AIM: • Literature review regarding empowering leadership and AMS in health care • Assessment of the impact of such a leadership style on AMS • CONCLUSION • A leadership style focusing on empowering frontline physicians to take over individual responsibility in the application of AMS is a potential strategy to improve the outcome of children receiving antibiotics or interventions

  20. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature ReviewFrontiers in Ped. 2018; 12 Oct doi: 10.3389/fped.2018 Leadership Styles • Directive • Maintains Control • can be strong and effective when necessary; e.g. : Directive leadership in an emergency trauma room is most effective when pressure and urgency is high and teams are inexperienced • Empowered • Hands off/ coordinates control • does not delegate orders top-down, but builds a team of direct caregivers and empowers them to take over responsibility and make their own decisions. • The leader is perceived as a coach • Leadership who enables team members to take over direct responsibility and which emphasize the importance of a positive team atmosphere is well known in industries outside health care

  21. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature ReviewFrontiers in Ped. 2018; 12 Oct doi: 10.3389/fped.2018 RESULTS: • Five articles were included in the literature review. All five studies concluded that • An empowering leadership style may lead to a higher engagement of physicians which resulted in: • Improved AMS as reduced rate in HAIs and improved prevention of MRSA infections. • From 2015 to 2017, antibiotic days overall and antibiotic days for culture-negative situations declined significantly • Over 3 years, suspected and proven VAP- and CLABSI-episodes decreased in 2017.

  22. Impact of Empowering Leadership on Antimicrobial Stewardship: A Single Center Study in a Neonatal and Pediatric Intensive Care Unit and a Literature ReviewFrontiers in Ped. 2018; 12 Oct doi: 10.3389/fped.2018 Impact of change from control-driven to empowering leadership of ASM

  23. Habits of highly effective people Covey SR. The 8th Habit: from Effectiveness to Greatness. Free Press, 2004. NY 8. From Effectiveness to Greatness • Great achievers expressing their voice through the use of their intelligences. Achievers for example • develop their mental energy into vision • develop their physical energy into discipline • develop their emotional energy into passion • develop their spiritual energy into conscience – their inward moral sense of what is right and wrong and their drive towards meaning and contribution.[ • "5 Cancerous Behaviors” that inhibit people's greatness: • Criticism • Complaining • Comparing • Competing • Contending

  24. The purpose of this guidance document is to outline the knowledge and skills that are needed to lead an antimicrobial stewardship program. • Society for Healthcare Epidemiology of America has partnered with other leaders in advancing the field of antimicrobial stewardship, including the Infectious Diseases Society of America, Making-A-Difference in Infectious Diseases, the National Foundation of Infectious Diseases, the Pediatric Infectious Diseases Society, and the Society of Infectious Disease Pharmacists Infection Control and Hospital Epidemiology. 2014; 35:1444-1451

  25. Hospital Stewardship-HOW? • Antimicrobial restriction • Prospective evaluation and feedback • Interventions • Appropriate agent (based on susceptibility) • Avoid discordant therapy • De-escalation • Stop if no antimicrobial warranted • Stop MRSA therapy if no MRSA • Colonization; Asymptomatic bacteriuria • Dose Optimization • Based on renal function, weight, MIC • Switch to oral • Reduce duration • Allergy assessment

  26. Difference between Consultation and Stewardship Ostrowsky B et al. Clin Infect Dis. 2018; DOI: 10.1093/cid/cix1093 • Formal consultation one patient at a time is distinct from that of ASP leadership. • More patients receive ABX than formal ID consultation • improves the health and safety of an expanded patient population. • ASP ID physician provides unique ID expertise • triages more complicated cases, • works with a variety of prescribers, • provides peer-to-peer education, • provides program leadership cultivating a culture that supports stewardship. • Distinct from hospital epidemiologist • but complementary to the function of ASPs

  27. “Leadership and learning are indispensable to each other.” John F Kennedy

  28. Leading with Knowledge From Goff et al. Clin Infect Dis 2017

  29. Leadership Tips for Introverts • Understand your strengths as an introvert • Better observers • listen and scan situation; think critically before action • Focus on what is within your control • Be prepared to put yourself out there • Important to push yourself to speak up when it matters Post J. Business News Daily April 7, 2017

  30. C-Suite Circumstances: • Hospital administrators have limited amount of discretionary funds available • Administrators’ awareness of the need to implement antimicrobial stewardship due to regulatory standards does not guarantee they will support a program that is effective and adequately staffed. • Administrators are accustomed to sense of urgency for funding requests • An antimicrobial stewardship program is more likely to be funded if it does not harm existing operations that are equally, or more, important to the financial and operational stability of the system • Your ability to push your agenda to the C-suite is related to your established credibility Open Forum Infectious Diseases 2018

  31. Standard pitch: • If funded, the ASP will do the following: • Reduce ABX days of therapy, length of therapy, and ABX cost • Attenuate the rate of emergence of resistant bacteria • Increase access to molecular diagnostics and biomarkers to ensure that patients get individualized specific therapy rather than clinician’s having to guess the etiology of infection and overuse empiric therapy • The result is better patient care and fewer readmissions • Ensure compliance with Joint Commission-mandated standards • Avoid CMS discounts for an inadequate ASP program • In short, with your help, funding an ASP will result in a solid return on investment manifest as better patient care coupled with less antibiotic exposure. The results will include fewer adverse drug reactions, less antibiotic resistance, and less expense to the medical center.

  32. Chloe Chong

  33. Communication in an Interprofessional Antimicrobial Stewardship Program 1. Beganovic M, LaPlante KL. Rhode Island Med J. June 2018 45-49 2. Foral PA et al. J Am Osteopathic Assoc. 2016; 116: 588-593 One major theme across all healthcare settings is that ASPs must collaborate with facility leadership and key stakeholders at each institution in order to have an impactful benefit on patient quality of care, and safety1 A collaborative interprofessional team environment ensures optimal patient-centered care.2

  34. Successful ASPImportance of Communication • Merriam-Webster Dictionary • A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior • “It’s a body language, eye contact, the grinning, the little signals that go on between people.” • Keith Richards. Rolling Stone 1994 • Personal rapport • e.g. “ a lack of communication between old and young persons.”

  35. Means of Communication • Means • Face-to-face • Often most effective • Email • Chart notes • Part of record or not • Pager • Cell phone • Institutional secure app • Other • EMR sign in reminders • In all cases consider Rapport

  36. Communication Errors 1. Linkin DR et al. Infect Control Hosp Epidemiol . 2007; 28(12): 1374–1381; 2. Myers J. J Infect. Dis. 1984; 150: 797-802. • Effect of Communication Errors During Calls to an Antimicrobial Stewardship Program1 • Retrospective study • 42% of the calls had inappropriate antimicrobial recommendations • In part due to inaccurate communication • ‘Curbside Consults2 • Communication often inaccurate

  37. Establishing a successful ASP requires a plan to achieve consensus. • Having support of respected staff is extremely important . • ASP interventions are focused on changing provider prescribing Behavior. • ASP to be presented to the entire medical staff with evidence of the benefit. • Emphasize that ASP is helpful to the clinicians care of patients • Terminology such as “restricted” antibiotics viewed as controlling; can threaten colleagues. Changing the terminology to “protected” conveys a positive message. Clin Infect Dis. 2016; 63: 532-38

  38. UNDERSTANDING WHY THERE IS A PROBLEM: DUE PROCESS • Understanding is essential for effective interventions • Rejection often observed in more experienced practitioners • relying on past practices that may have had positive outcomes • felt safer. • Provide real-time face-to-face evidence-based REC • allows for understanding of rejection • possible educational resolution of disagreements • may be legitimate reasons for rejection not documented in record • If still problem: Due process Clin Infect Dis. 2016; 63: 532-38

  39. Chloe Chong

  40. March, 2015

  41. Rapid microbiologic tests provide opportunities for antimicrobial stewardship programs to improve antimicrobial use and clinical and economic outcomes. • Rapid microbiologic tests are considered “game changers” and represent a significant advancement in the management of infectious diseases. Clin Infect Dis. 2014 Suppl 3; 59: S134-145

  42. CAP (empiric ABX; consider epidemiology, host factors; early data: Gram stain, Urinary Antigens ) + Viral PCR NO YES PCT < 0.1 PCT <0.1 YES YES NO NO Individualize; If < 0.2 usually STOP ABX; > 0.2 Cont. ABX STOP ABX Individualize; If < 0.2 usually STOP ABX Individualize usually STOP ABX SUMMA Stewardship

  43. Virus positive without + bacteria identified: median PCT 0.12 (<0.10-0.14); mean duration ABX 2.8 days • Virus positive with + bacterial culture: median PCT 0.62 (0.1-47); mean duration ABX 6 days IDWeek, 2017

  44. The Future: Game Changers?? LRTI multiplex PCR panels Curetis Unyvero BioFire

  45. A qualitative analysis of implementation of antimicrobial stewardship at 3 academic hospitals: Understanding the keyinfluences on successJeffs et al. Can J Hosp Pharm. 2015; 68:395–400. • Successful implementation of an antimicrobial stewardship program should include the following key themes: • 1.Get the right people on board; • 2.Build collegial relationships (formally and informally) with prescribers; • 3.Establishing a track record

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