Relentless Improvement: Overcoming the “Active Resisters and Organizational Constipators” to Drive Change

Diagnostic stewardship refers to the appropriate ordering, collecting, processing, and reporting of laboratory tests in order to optimize clinical outcomes and limit the spread of antimicrobial resistance, and it is needed in pediatric critical care clinical decision-making.¹ In this month’s issue of the Journal, Woods-Hill and colleagues set out to improve diagnostic stewardship in our use of blood cultures in critically ill pediatric patients.² By developing consensus recommendations, the group of Bright STAR (Blood culture improvement and diagnostic stewardship for antibiotic reduction in critically ill children) authors propose an algorithm for ordering blood cultures, with the aim of reducing false positive results, unnecessary use of antibiotics, length-of-stay, and costs. This consensus recommendation by the group is the first step to improving blood culture practices in the pediatric critical care population.

The report is outstanding and the recommendations are clear and concise.² That said, this is only an initial – albeit crucial – step to making progress. In our experience, the next step is far harder, and that is convincing our colleagues in pediatric intensive care units (PICUs) across the country, and our institutions, to implement the proposed recommendations. The Bright STAR group does suggest some strategies for implementing their proposals, but much more work is needed in the centers where we practice. For example: securing the support and “buy-in” from leaders and key stakeholders; adapting the recommendations for our individual PICUs with a dedicated and committed group of practitioners; and, using a system of audit that is able to give timely feedback to PICU teams about individual compliance. This work will fall largely on the physician and nursing teams that lead quality improvement initiatives at each of our hospitals.

Over the last decade, there has been a huge expansion in the capacity to bring about quality improvement work across PICUs, as evidenced by the increase in publications detailing these projects.³ While the processes described in such reports can be helpful for a team trying to replicate a particular project, the field of pediatric critical care medicine has yet to embrace the domain of expertise called implementation science. Implementation science bridges the gap between research and practice by improving our knowledge of barriers as well as facilitating effective practice changes. Even though there may be many barriers to implementing evidence-based guidelines and recommendations, most can be overcome by using the already published frameworks of implementation science.^4–8 Therefore, we look forward to more work from the Bright STAR group that details the implementation of its recommendations and their impact on PICU patient care.

In our experience, there are key barriers to improving the quality of care and – to borrow a phrase from the literature – the greatest challenges are overcoming “the active resisters and organizational constipators” within our institutions and units.⁹ In this context, “active resisters” are those who directly oppose changes to practice and thereby impede the implementation of new methods such as the recommendations proposed in the Bright STAR report. The “organizational constipators” are those leaders with influence who thwart the necessary actions needed to support and propel an implementation. While there are strategies to combat both of these hypothetical obstacles, many are challenging for those not in a position of leadership. Hence, for improvers trying to drive quality and standardization of clinical practices, we propose some tips for successful implementation of change in the PICU (Table).

Table:

Truth Behind Successful Implementation of Recommendations and Guidelines

• Use evidence-based guidelines and implementation frameworks to translate research, recommendations and guidelines into practice

• Provide benchmarking data both between and within your organization to drive improvement

• Recruit champions for change who model and promote interventions and arm them with data

• Include any “organizational constipators” early in the plan so that you may gain the necessary support; you may need a work-around if this strategy does not work

• Be a relentless pursuer of improvement

Start with the evidence. In this issue of the Journal we have the Bright STAR recommendations for blood cultures in critically ill children.² Then, use one of the many published frameworks for bringing about implementation,¹⁰ including those of the Institute of Healthcare Improvement’s Framework for Spread,¹¹ the Pronovost et al. Model for Translating Evidence into Practice,⁸ and the PARiHS (Promoting Action on Research Implementation in Health Services) report,¹² to name just a few. A framework will enable you to develop a formal implementation plan and outline a robust path to success, but it may not necessarily guarantee it. For success, it is also vital at an early stage to tackle any barriers to implementation, including those posed by active resisters; be inclusive and gain their support, listen to feedback and input, and when reasonable, adapt the implementation plan or practice change(s).^9,13 Next, educate the team with data about the targeted gap(s) and, when available, use a benchmark, which may include comparisons between centers, units, and/or clinicians.¹⁴ Audits and feedback have variable impact but are an effective strategy to motivate a change in professional practice when they are timely, individualized, actionable, and not punitive.¹⁵ Collecting and benchmarking your data not only allows you to track the progress of a project, but you can also give it to any “resisters” and “constipators”, hopefully inspiring and persuading them to align with the aims of the project. Last, identify your champions who will model and promote the interventions. Coach and prepare them for the role by arming them with information and data.¹⁴ In regard to any organizational constipators, also include them early (or, as they surface) to combat obstructions to the project. While they may be an unwanted collaborator, gaining their support may be what is needed for successful implementation and sustainability of a project. However, sometimes it is necessary to learn how to make organizational processes change without such obstructers, which often requires support from more senior leadership and – of course – will be facilitated by evidence.⁹

In conclusion, the report from the Bright STAR group² is a welcome roadmap to do better with the blood culture testing component of diagnostic stewardship in the PICU. Now, our teams need the drive and focus to be relentless improvers.