Table 1.

Major Themes and Subthemes With Examples and Representative Quotes.

Theme/subtheme	Example facilitators or barriers identified	Representative quotes
1. Importance of a culture supportive of antibiotic stewardship throughout the organization.
Importance of leadership in fostering broad acceptance or “buy-in” for antibiotic stewardship principles	● Facilitators of “buy-in” described: - Having a member of leadership part of the antibiotic stewardship team or trained in infectious diseases (n = 3) - Importance of antibiotic resistance and antibiotic stewardship nationally (n = 2)	I can tell you that the support from leadership is definitely a strength because we do have the chief of staff on our [antibiotic stewardship] service . . . [Staff] are very supportive . . . in general when it comes down to antimicrobial use . . . and having a chief of staff who is trained in infectious diseases, being part of your committee, does help out quite a bit. I think a lot of people do recognize that antimicrobial stewardship is an important . . . focus of the VA at the moment, as well as nationally. . . . I turn on the news any day of the week and . . . hear about new antibiotic resistant bacteria becoming a major health concern. So . . . from all perspectives [of] a healthcare team [appropriate antibiotic use] should be one of . . . the number one priorities.
Importance of a strong relationship between the house-staff and the antibiotic stewardship team for “buy-in”	● Facilitators to a strong relationship described: - Dedicated team - Consistent members - Established and ongoing relationship - Numerous interactions (n = 4) ● Barriers to a strong relationship described:  Staff turnover	Having . . . worked here for many years . . . with the internal medicine service, having an already . . . ongoing relationship with many of the physicians does help. Now transitioning to this role [as a stewardship pharmacist] . . . to be able to approach them, and kind of explain . . . what we are doing and where things are headed helps a little more with buy-in. . . . Having a smaller group . . . instead of having 15 different people, kind of trying to tell [physicians] the same thing or intervene. I think is a good thing and is helpful . . . The other thing would probably be just physician buy-in . . . I feel that . . . having more opportunities . . . to be involved and working with the physicians . . . just building those relationships . . . would be very beneficial. As far as stewardship acceptance rate . . . it varies according to just how well the pharmacist is trusted and how valuable the physician team at the facility sees the pharmacist. . . . I think everybody should be involved. [laughs] All the physicians . . . nurses . . . I think we could always be doing a better job . . . A lot of our house-staff . . . is rotating so by the time they get used to . . . the way we do things here . . . then they change or they leave and go somewhere else.
2. Lack of time for antibiotic stewardship at the organization and individual levels regarded as a program as a weakness.
Insufficient time from core team members for clinical antibiotic stewardship duties (n = 8)		Another [weakness] is just manpower. We don’t have the hours to spare right now for me . . . or for [another pharmacist] to sit down and do purely stewardship activities. We have a physician . . . [but is] pulled in many different directions [and] . . . doesn’t always have the time . . . for this [antibiotic stewardship] program. So I mean . . . that’s a weakness in that no one seems to have much time [laughs].
Insufficient time for other activities related to antibiotic stewardship beyond clinical care	● Barriers described: - Lack of time for IT duties (n = 4) - Lack of time for other duties (ie, administrative and education) (n = 2)	I think probably the top [wish-list item] would be . . . for sure more IT support. I don’t think there is any doubt about that because there’s lots of things that I would like to do, lots of ideas, there’s just no way that I can make them happen without someone else helping me. When it comes down to things to improve, I think we’re really working harder on the benchmarking and trying to collect that information, which is very hard . . . we did it the old fashioned way by daily reports . . . which is way too labor intensive and it takes away from the . . . patient care focus of it so . . . that’s something that we are definitely working on . . . the benchmarking areas. Basically, we don’t really have much tracking at all yet . . . I tracked patients . . . and then went in manually to read and see notes to see whether they got antibiotics or not . . . That’s kind of a back door way, but we had to do [it that way] with being down an IT person, that’s the only way we could really think of doing it. . . . And really having enough time to balance not only doing the clinical aspect but . . . doing more of the policy work and other things like that is definitely a downside at the moment . . . Right now it’s hard to get as many interventions done as we might like, knowing there has to be time devoted for the kind of the admin parts of the process as well. We haven’t done very much education. So education to providers hasn’t really happened to this point . . . a weakness is just not being able to . . . do any of our education up to this point.
3. Respondents described a lack of connection within an organization as a weakness.
Support and guidance for antibiotic stewardship split across multiple campuses	● Barriers described: - Lack of consistent on-site access to support at all locations. (n = 3)	One area . . . that we want to expand on is . . . outpatient antimicrobial use. But . . . [our organization] is very . . . dispersed . . . so the [outpatient facilities] don’t always have the support or the know-how or somebody to follow-up on. Our outpatient providers probably would want more help and support and I think we definitely want to move in that route . . . I don’t know if we need [our] own [antibiotic stewardship program] here, but we definitely . . . could use more support, more overlap [from the acute care location]. I think that would definitely be helpful . . . or if there was some guidance about what we could do on a regular basis locally to make sure [antibiotic use is] appropriate . . . Versus just our own efforts, making it kind of standard across campuses.
Reliance on “less-optimal” non face-to-face communication methods (n = 3)	● Barriers described: - Difficulties in performing patient evaluations remotely - Push back from house-staff - Difficulties in meeting as a group to discuss antibiotic stewardship goals	Its hard with the CLC because we’re up here and they’re down there to find out if the patient is really sick. So . . . where here . . . you can go to go see the patient to find out more [of] what’s going on by talking to the patient or talking to . . . the people taking care of [the patient] directly. [At the] CLC . . . you’re talking to someone on the phone . . . Cuz sometimes the patient will have a . . . say positive culture . . . but the patient is not sick . . . It’s hard [to know that] when you talk to someone on the phone versus talking to someone in person. I think the stewardship team is a little bit distant from the rest of the medical facility. One, in that they’re in a different building than where . . . the patients are actually being treated. And two, just because the medical residents never really see us. And so . . . because of that when we call them . . . I think we get some push back and some hesitancy as far as accepting our recommendations. Just because they’re not familiar with us . . . they can’t put a name to a face with us . . . And I think that’s a weakness. . . . Having periodic meetings as a group . . . a whole group . . . where we are all able to dedicate time and talk about what our goals are as a program . . . and how do we carry out those goals. It makes it hard . . . that I am in [the main acute care location] and some people are in [the CLC location]. One of our providers is now off-site at times at another clinic, so everyone’s schedules are just all over the place, and not having that face-to-face, meeting, or connection, it just makes it much more difficult.
Lack of regular interaction with the antibiotic stewardship team at locations other than the main acute care facility (n = 3)	● Barriers described: - Lack of visits - Lack of regular education/updates - Lack of communication	I’m a consultant when they call me, so I don’t physically go [to the CLC location]. I don’t [spend any time on antibiotic stewardship at the CLC] . . . unless they call me . . . Other than that, I don’t go to the CLC at all. . . . There is no formal education for antibiotics . . . that happens down at the [CLC location] campus. I don’t really feel like we get . . . too many updates on that sort of thing . . . I think it would be helpful to have just . . . some more communication kind of from the specialty services about . . . how we can help guide the physicians here and make sure the patients are . . . treated . . . as best they can be . . . I mean from my perspective . . . we don’t get a whole lot of information or updates about . . . antibiotic usage . . . I mean maybe we get communication . . . a couple times a year . . . But . . . it’s not regular at all. So . . . for us [appropriate antibiotic use around the CLC] doesn’t [come up in conversation] . . . It’s a little bit tougher with the CLC because our departments are kind of separated and we don’t have a pharmacist that goes down there and sits down with them. So any time they need to get in contact with us they call us. And usually it’s more of a one-way communication channel, with us calling them . . .

Note. VA = veterans affairs; IT = information technology; CLC = community living center.