anchorage in orthodontics

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  • Systems based approach needed – ‘’to embed in all aspects of care and support’’ Sustainability –’’depends on embedding it within the organisation itself- not a reliance on short-lived campaigns, personal crusades etc’’ Lack of Management awareness re infection risks in their decision making Altering individual behaviour inadequate………..- A organisation wide approach with strong leadership – this also ensures flexibility in facing emerging and re- emerging threats- and to be able to deal with the multiple directives…….
  • Status of infection control and hospital epidemiology…..BOTH clinically and academically- without the machismo and powerbase of other med and surg specialities National directives- that are focused on a single organism only- or directives aimed only at nurses/matrons not consultants ….
  • Patient care the driver NOT one particular single organism….
  • Facilitates targeted activity ----and rapid adoption of best practice- ‘’and care bundles’’……
  • Reinforces integrated infection control and antibiotic control Risks: eg BSI risks, environment scores…..
  • BUZZ words ‘’de-escalation’’ and ‘’bundle’’- just mean stepping down and package of measures……
  • Predetermined clinical criteria
  • anchorage in orthodontics

    1. 1. Organisational Issues www.hi-dentfinishingschool.blogspot.com
    2. 2. How can a Hospital Deliver good Antibiotic Stewardship? <ul><li>A Clinician’s and Epidemiologist’s </li></ul><ul><li>(and DIPC’s) Perspective </li></ul><ul><li>Effective Antibiotic Teams </li></ul><ul><li>Infectious Diseases Pharmacists </li></ul><ul><li>Intelligence underpinning activity </li></ul><ul><li>Organisational development in Acute Trusts </li></ul>
    3. 3. <ul><li>Multidisciplinary working NHS plan DoH 2000 </li></ul><ul><li>Recommended for antibiotic management </li></ul><ul><li>IDSA Marr et al ’88 JID157 , EU Copenhagen Recommendations 98 </li></ul><ul><li>A ‘multidisciplinary and systems oriented approach catalysed by hospital leadership’- Goldmann et al ‘ 96 JAMA 275 </li></ul><ul><li>‘ Nominated lead’ for Trusts- HSC 1999/049 Resistance to Antibiotics </li></ul><ul><li>Importance of respected clinical leadership </li></ul><ul><li>Burke et al ’96 Hosp Pharm 31, Garey et al ICAAC 2000 </li></ul><ul><li>DIPC for each Trust ‘Authority to challenge antibx prescribing’ - Dec 2003 DoH </li></ul><ul><li>Impact on clinical outcomes, LOS and cost not realised </li></ul><ul><li>Future-better research, better evidence base, more analysis of policy, health care delivery and quality improvement BMJ Godlee Jan,May 2006 </li></ul>Antibiotic Teams
    4. 4. <ul><li>Multidisciplinary working NHS plan DoH 2000 </li></ul><ul><li>Recommended for antibiotic management </li></ul><ul><li>IDSA Marr et al ’88 JID157 , EU Copenhagen Recommendations 98 </li></ul><ul><li>A ‘multidisciplinary and systems oriented approach catalysed by hospital leadership’- Goldmann et al ‘ 96 JAMA 275 </li></ul><ul><li>‘ Nominated lead’ for Trusts- HSC 1999/049 Resistance to Antibiotics </li></ul><ul><li>Importance of respected clinical leadership </li></ul><ul><li>Burke et al ’96 Hosp Pharm 31, Garey et al ICAAC 2000 </li></ul><ul><li>DIPC for each Trust ‘Authority to challenge antibx prescribing’ - Dec 2003 DoH </li></ul><ul><li>Impact on clinical outcomes, LOS and cost not realised </li></ul><ul><li>Future-better research, better evidence base, more analysis of policy, health care delivery and quality improvement BMJ Godlee Jan,May 2006 </li></ul>Antibiotic Teams
    5. 5. Increasing Role and Value of Teams <ul><li>Antibiotic management part of QA programmes, Trust and Directorates Performance monitoring, Clinical Governance, KPI’s </li></ul><ul><li>Integration of Antibx control with Infection Prevention and Control NAO 2004 </li></ul><ul><li>Some DIPCs will be pharmacists </li></ul><ul><li>LOS and Care management guidelines driving change </li></ul><ul><li>Greater emphasis on de-escalation and stopping </li></ul><ul><li>Moussaoui et al BMJ June 10 th 2006 </li></ul>
    6. 6. <ul><li>Duration of antibiotic therapy and </li></ul><ul><li>Microbiologist/Infectious diseases </li></ul><ul><li>specialist input </li></ul><ul><li>Corona et al. JAC 52 (5): 849. (2003) </li></ul><ul><li>254 ITUs, 34 countries </li></ul><ul><li>The greater the specialist input, the shorter the duration of therapy (P < 0.0001) </li></ul>
    7. 7. Teams of the Future <ul><li>More systems based strategic approach </li></ul><ul><li>Adopting behavioural and organisational strategies </li></ul><ul><li>Pulcini 2006 JAC, Tan 2006 Qual Safe healthcare </li></ul><ul><li>Policies to the bedside – care bundles, management pathways </li></ul><ul><li>Supported by better intelligence </li></ul><ul><li>Operational/strategic roles? -Do they need to be multidisciplinary operationally? </li></ul><ul><li>More senior clinical roles for pharmacists, with specialist training, professional development and support </li></ul>
    8. 8. Ideal Clinical Team? <ul><li>Microbiology/ID consultant </li></ul><ul><li>ID Pharmacist </li></ul><ul><li>SpR micro/ID </li></ul><ul><li>Directorate pharmacist </li></ul><ul><li>MLSO/ Technician </li></ul><ul><li>Hospital epidemiologist (with data manager/IT support, electronic prescribing) </li></ul><ul><li>Infection control </li></ul><ul><li>Speciality representatives (docs and nurses) </li></ul><ul><li>Bed manager ( discharge planning, OPAT) </li></ul>
    9. 9. The ID Pharmacist <ul><li>Education </li></ul><ul><li>Expert advice </li></ul><ul><li>Control and optimising Rx </li></ul><ul><li>Infection Prevention </li></ul><ul><li>Reduce SSI- optimise surgical prophylaxis </li></ul><ul><li>Reduce C. difficile </li></ul><ul><li>De-escalation </li></ul><ul><li>Eradication protocols </li></ul><ul><li>IV to oral </li></ul><ul><li>IV management, lines on prescription </li></ul><ul><li>Coated devices </li></ul>
    10. 10. The ID Pharmacist <ul><li>Education </li></ul><ul><li>Expert advice </li></ul><ul><li>Control and optimising Rx </li></ul><ul><li>Infection Prevention </li></ul><ul><li>Reduce SSI- optimise surgical prophylaxis </li></ul><ul><li>Reduce C. difficile </li></ul><ul><li>De-escalation </li></ul><ul><li>Eradication protocols </li></ul><ul><li>IV to oral </li></ul><ul><li>IV management, lines on prescription </li></ul><ul><li>Coated devices </li></ul><ul><li>Policies and implementation </li></ul><ul><li>Surveillance and audit </li></ul><ul><li>Awareness of local patterns of prescribing, resistance, infections, outbreaks etc </li></ul><ul><li>Awareness of flagged patients/alert organisms </li></ul><ul><li>Occupational health eg PEP, vaccination </li></ul><ul><li>Emergency planning and preparedness </li></ul>
    11. 11. Future Role for ID pharmacist <ul><li>More Strategic </li></ul><ul><li>Greater leadership role </li></ul><ul><li>Better trained </li></ul><ul><li>Provide more medical training </li></ul><ul><li>Greater clinical partnerships, and recognition </li></ul><ul><li>Microbiology off site and centralised </li></ul><ul><li>More linkage with infection prevention </li></ul><ul><li>Integrated into Clinical Governance </li></ul><ul><li>Better epidemiology and monitoring </li></ul><ul><li>Organisational development </li></ul><ul><li>Leading roles in emergency planning and preparedness </li></ul>
    12. 12. But in UK: Need for Training <ul><li>US and Canada full time residency programmes in ID pharmacy practice, followed by fellowships in practice or research </li></ul><ul><li>No postgrad training </li></ul><ul><li>existed in the UK </li></ul>
    13. 13. Need for Training <ul><li>US and Canada full time residency programmes in ID pharmacy practice, followed by fellowships in practice or research </li></ul><ul><li>No postgrad training </li></ul><ul><li>existed in the UK </li></ul><ul><li>Until: Oct 2003 </li></ul><ul><li>MSc programme </li></ul><ul><li>Imperial/ HPA / </li></ul><ul><li>APU Hammersmith </li></ul><ul><li>[email_address] </li></ul>
    14. 14. The Future for Training <ul><li>MSc -expansion to better support UK wide pharmacists </li></ul><ul><li>Professional development aspects enhanced </li></ul><ul><li>Clinical role promoted </li></ul><ul><li>Graduates to provide input, support, mentorship, shape course </li></ul><ul><li>PhDs encouraged </li></ul><ul><li>Impact of graduates assessed </li></ul><ul><li>Modules, seminars, lectures multidisciplinary with ID/micro trainees etc </li></ul>
    15. 15. <ul><li>If Teams are to be more strategic and influential- they need: </li></ul><ul><li>Local and national intelligence </li></ul><ul><li>Organisational and systems based approaches to embed and sustain best practice, and address Institutional, cultural and professional barriers </li></ul>
    16. 16. Intelligence <ul><li>Systems to support information gathering </li></ul><ul><li>Appropriate IT </li></ul><ul><li>Surveillance schemes </li></ul><ul><li>Real time monitoring </li></ul><ul><li>Generate triggers for action </li></ul><ul><li>Audit Programme </li></ul><ul><li>Analytical resources </li></ul><ul><li>Framework for feedback and action </li></ul><ul><li>Data informing local policies </li></ul><ul><li>Provide decision support </li></ul>LDS Hospital, Salt Lake City team
    17. 17. Systems to monitor: <ul><li>Prescribing </li></ul><ul><li>Organisms </li></ul><ul><li>Resistance </li></ul><ul><li>Mismatch </li></ul><ul><li>Patient and Disease patterns </li></ul><ul><li>Linked to patient info, admin info, bed tracking, theatre, pathol databases, physician info </li></ul><ul><li>Ability to integrate with infection control databases, alert organisms, clinical incidents, line usage, SSI, mandatory reporting databases, appraisals, training </li></ul>
    18. 18. Organisational Change required <ul><li>Much expertise, not harnessed effectively </li></ul><ul><li>Small teams in huge Trusts without major strategic input </li></ul><ul><li>Not closely linked to management framework </li></ul><ul><li>Systems based approach needed </li></ul><ul><li>Sustainability </li></ul><ul><li>To be a core part of corporate governance </li></ul><ul><li>Create organisational learning </li></ul><ul><li>Culture and behaviour of whole Trust to change </li></ul>
    19. 19. Barriers to Address <ul><li>Historically in UK -Lack of public health leadership in acute trusts </li></ul><ul><li>Clinicians and managers separation from public health responsibility </li></ul><ul><li>Complacency, unaware of risk </li></ul><ul><li>Consultant ‘autonomy’, resistance to standardising practice </li></ul><ul><li>No perceived individual responsibility </li></ul><ul><li>Multiple parallel hierarchies </li></ul><ul><li>Competing priorities,clinical and managerial </li></ul><ul><li>Lack of shared vision </li></ul>
    20. 20. Platform for Organisational Change <ul><li>Patient care the driver </li></ul><ul><li>High Clinical profile essential </li></ul><ul><li>Multidisciplinary engagement </li></ul><ul><li>Multiple Leaders </li></ul><ul><li>Collaborative </li></ul><ul><li>Addressing local issues </li></ul><ul><li>Integrate with infection control </li></ul><ul><li>Use existing Clinical Governance framework </li></ul><ul><li>Chief executive backing </li></ul><ul><li>Directorate accountability </li></ul><ul><li>‘ HOMIP’- HSJ Feb 2006 </li></ul>
    21. 21. Learn from other worlds… <ul><li>Industry (e.g. Airlines- safety culture, Food industry-HACCP) </li></ul><ul><li>Business and Management (organisational development and change management) </li></ul><ul><li>Military ( e.g. The ‘Afterburners’: Delivering a mission in combat situation, ‘flawless execution’ in a changing </li></ul><ul><li>and environment with ‘plan-brief-execute’ (with </li></ul><ul><li>continuous crosschecks) then debrief, addressing task saturation and ensuring shared motivation </li></ul><ul><li>Politics ( e.g. IHI 100k lives campaign- ‘’Soon is not a time, less is not a number’’ Don Berwick) </li></ul><ul><li>Advertising, communications and the media </li></ul><ul><li>Behavioural sciences </li></ul>
    22. 22. Business and Management <ul><li>Performance monitoring </li></ul><ul><li>Accountability </li></ul><ul><li>Traffic lights </li></ul><ul><li>Targets </li></ul><ul><li>Balanced score cards </li></ul>
    23. 23. The Balanced Scorecard <ul><li>A framework to measure performance beyond finances in private industry </li></ul><ul><li>Align performance measures with strategic mission and goals- so not only measure performance but factors driving performance. </li></ul><ul><li>A basis for executing good strategy well and managing change successfully </li></ul><ul><li>Caution: -you get what you measure </li></ul><ul><ul><li>-skews activity </li></ul></ul><ul><ul><li>-needs regular refreshing and updating </li></ul></ul><ul><li>Kaplan and Norton 1996 Harvard Business School Press </li></ul>
    24. 24. Local Directorate Accountability <ul><li>Follows decision making and funding </li></ul><ul><li>GMs and Clinical Directors accountable </li></ul><ul><li>Clinical leaders identified </li></ul><ul><li>Reinforces ownership </li></ul><ul><li>Embed specialist surveillance </li></ul><ul><li>Facilitates targeted </li></ul><ul><li>activity and rapid </li></ul><ul><li>adoption of best practice </li></ul><ul><li>HOMIP- HSJ Feb 2006 </li></ul>
    25. 25. Local Performance Management <ul><li>2004-5 Infection targets in ‘balanced score card’ for each clinical directorate, reviewed monthly </li></ul><ul><li>Core infection outcome measures agreed- includes antibiotic use Dean et al Int J Pharm Prac 2002 </li></ul><ul><li>Supplemental speciality specific measures </li></ul><ul><li>Traffic light system </li></ul><ul><li>Information on risks </li></ul><ul><li>expanding </li></ul><ul><li>‘ Post op HAI’ if on </li></ul><ul><li>antibx 48 hours post </li></ul><ul><li>elective surgery </li></ul>
    26. 26. <ul><li>This Framework: </li></ul><ul><li>Addresses clinical governance in antibiotic prescribing </li></ul><ul><li>Continually reinforces stewardship ( clinically and managerially) </li></ul><ul><li>Develops supportive networks (ward pharms etc) </li></ul><ul><li>Effectively works cross </li></ul><ul><li>directorates and cross sites </li></ul><ul><li>Efficient engagement </li></ul><ul><li>with clinical teams </li></ul><ul><li>Promotes understanding of </li></ul><ul><li>risk and value of standardised systems </li></ul>
    27. 27. Systems and Standardised care <ul><li>For risk reduction and quality improvement </li></ul><ul><li>Check lists, aviation industry tools </li></ul><ul><li>Consultant autonomy challenges </li></ul><ul><li>NB tools for management, finance (and litigation) directed monitoring </li></ul><ul><li>ICPs </li></ul><ul><li>Care bundles </li></ul><ul><li>-SSI, ventilators, Central lines etc </li></ul><ul><li>-IHI ‘100K Lives’ and DoH </li></ul><ul><li>‘ Saving lives’ campaign </li></ul><ul><li>-Antibx in SSI and Sepsis </li></ul><ul><li>critical care bundle </li></ul>
    28. 28. What Is a Bundle? <ul><li>A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. </li></ul><ul><li>The science behind the bundle is so well established that it should be considered standard of care. </li></ul><ul><li>Bundle elements are dichotomous and compliance can be measured: yes/no answers. </li></ul><ul><li>Bundles avoid the piecemeal application of proven therapies in favor of an “all or none” approach. </li></ul>
    29. 29. The ‘Antibiotic Care Bundle’…… <ul><li>Clinical criteria for initiation </li></ul><ul><li>Actively get microbiol specimens </li></ul><ul><li>Empiric initial choice based on local policy </li></ul><ul><li>Remove sources foreign body, surgery </li></ul><ul><li>Modify when microbiol results through </li></ul><ul><li>Daily review of antibx choice and continuation. </li></ul><ul><li>Regular expert input </li></ul><ul><ul><li>Cooke, Holmes in press 2006 </li></ul></ul><ul><li>Provides simple but rigorous check list, documentation and sign offs </li></ul><ul><li>Facilitates easy performance monitoring </li></ul>
    30. 30. Effective Practice? <ul><li>Unable to apply antibiotic stewardship adequately without changing the organisational culture and behaviour </li></ul><ul><li>Performance management successful in other complex organisations, and in changing directorate behaviour in other spheres </li></ul><ul><li>Creates organisational learning </li></ul><ul><li>Research required </li></ul><ul><li>McDonald, Wilson,Goodacre- Evaluating and Implementing new services BMJ 2006 14 th Jan </li></ul>

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