title: A Qualitative Analysis of Implementation of Antimicrobial Stewardship at 3 Academic Hospitals: Understanding the Key Influences on Success.
abstract: BACKGROUND
  Inappropriate use of antimicrobials is linked to the development and spread of drug-resistant pathogens and is associated with increased morbidity, mortality, lengths of hospital stay, and health care costs. "Antimicrobial stewardship" is the umbrella term for an evidence-based knowledge translation strategy involving comprehensive quality improvement activities to optimize the use of antimicrobials, improve patient outcomes, reduce the development of antimicrobial resistance and hospital-acquired infections such as Clostridium difficile, and decrease health care costs.
  
  
  OBJECTIVE
  To assess the perceptions and experiences of antimicrobial stewardship program leaders in terms of clinicians' attitudes toward and behaviours related to antimicrobial prescribing.
  
  
  METHODS
  In this qualitative study, semistructured interviews were conducted with 6 antimicrobial stewards (2 physicians and 4 pharmacists) at 3 academic hospitals between June and August 2013.
  
  
  RESULTS
  The following 3 key themes emerged from the interviews: getting the right people on board, building collegial relationships, and rapidly establishing a track record. The study results elucidated the role and mechanisms that the program leader and other antimicrobial stewards used to influence other clinicians to engage in effective utilization of antimicrobials. The results also highlighted the methods employed by members of the antimicrobial stewardship team to tailor their strategies to the local context and to stakeholders of participating units; to gain credibility by demonstrating the impact of the antimicrobial stewardship program on clinical outcomes and cost; and to engage senior leaders to endorse and invest in the antimicrobial stewardship program, thereby adding to the antimicrobial stewards' credibility and their ability to influence the uptake of effective antimicrobial use.
  
  
  CONCLUSIONS
  Collectively, these results offer insight into processes and mechanisms of influence employed by antimicrobial stewards to enhance antimicrobial use among clinicians, which can in turn inform future implementation of antimicrobial stewardship and strategies for organizational change in hospitals.
authors.affiliation: RN, PhD, is with the Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, and the Lawrence S Bloomberg Faculty of Nursing and the Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario.
authors.forename: Lianne
authors.initials: L
authors.lastname: Jeffs
authors.affiliation: MD, MSc, FRCPC, is with the Children's Hospital of Eastern Ontario, Ottawa, Ontario.
authors.forename: Nisha
authors.initials: N
authors.lastname: Thampi
authors.affiliation: RN, MN, is with Professional Practice - Nursing Research Portfolio, St Michael's Hospital, Toronto, Ontario.
authors.forename: Maria
authors.initials: M
authors.lastname: Maione
authors.affiliation: RN, is with Mount Sinai Hospital, Toronto, Ontario.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Steinberg
authors.affiliation: MD, SM, FRCPC, is with Mount Sinai Hospital, the University Health Network, and the Department of Medicine, University of Toronto, Toronto, Ontario.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Morris
authors.affiliation: MD, PhD, is with Mount Sinai Hospital and the Department of Medicine, University of Toronto, Toronto, Ontario.
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
keywords: antimicrobial stewardship implementation; mechanisms of influence; processes; qualitative research