Table 3.

Barriers to and Facilitators of Antimicrobial Stewardship Programs as Perceived by Participants Using the Systems Engineering Initiative for Patient Safety Framework

	Barrier	Facilitator
Organization	Lack of formal leadership support	Hospital accreditation
	Lack of a designated ASP leader	Designated ASP leader
	Lack of dedicated time for ASP	Regular meetings to discuss AS related topics
	Lack of specific ASP goals	Close collaboration with Microbiology
	Inadequate pharmacy and microbiology staffing	Type of hospital (size, type of administration)
	Excessive workload	External audits with feedback
	Compensation model/suboptimal salaries	Hospital leadership engages in AS activities (hospital director is member of AS committee, supports discussion around antibiotic practice changes)
	Frequent staff turnover
	Hierarchical relationships
	Limited understanding by hospital leaders of relevance/role of ASP
	Limited hospital budgets
	Work climate
Individuals	Low adherence to guidelines	Multidisciplinary work
	Nonevidence-based antibiotic practices	Time in the job
	Limited role of pharmacists in clinical decision-making	Empowering pharmacists (participation in rounds,
	Limited awareness of local antimicrobial resistance data
	Limited adoption of AS principles
	Fear of loss of prescriber autonomy
	Hierarchical relationships
Tasks	Inefficient processes for approval of restricted antimicrobials (too cumbersome, frontline providers find loopholes)	Integrating frontline providers in AS activities
	Microbiology laboratory has limited hours	Build ASP within infection prevention and control program
	Inefficiency in communication of microbiology results	Daily rounds
	Lack of integration with infection prevention and microbiology
	Inability to monitor antibiotic use data on a regular basis
	Limited role of pharmacist in antimicrobial management
	Limited training in quality improvement implementation
	Cost of medication
Tools and IT	Lack of IT support	Training in quality improvement/patient safety
	Lack of computers	Training in how to change behavior
	Lack of software for microbiology results	Electronic prescriptions
	Limited number of treatment guidelines	Robust EMR to allow efficient tracking of antimicrobial resistance/antibiotic use data
	Limited opportunities for AS training	Microbiology data integrated in EMR
	Lack of electronic prescriptions
	Data fragmentation
External environment	Lack of policies that facilitate implementation of ASP and/or promote AS
	Limited guidance from public authorities on initiatives to improve antibiotic use, ASP implementation, etc.
	Coronavirus disease 2019–related exhaustion	Participation of quality improvement projects
	Social climate	Reporting antibiotic use to public authorities
	Economic prosperity	Benchmarking

Abbreviations: AS, antimicrobial stewardship; ASP, antimicrobial stewardship program; EMR, electronic medical record; IT, information technology.