Wise Use of Antibiotics: Incorporating Quality Improvement into a Busy Clinic

Quality improvement (QI) is essential for all health care providers and staff, as it fosters a culture of excellence and ensures the highest standards of patient care. The American Academy of Pediatrics defines quality as the “right care for every child every time.”¹ Despite everyone’s best efforts, continued research, and treatment guidelines, there remains a quality gap where children do not receive recommended care or have suboptimal outcomes. We have published multiple articles over the last few years on optimizing antibiotic choice, dose and duration for common pediatric infections. If you are wondering how you can apply this evidence in your busy clinic, this article is for you!

The Institute for Healthcare Improvement (IHI) uses a framework called the “Model for Improvement” to guide improvement work.² This model highlights three questions: 1) what are we trying to accomplish? 2) how will we know that a change is an improvement? and 3) what change can we make that will result in improvement? The second part of the model is about making iterative changes through Plan-Do-Study-Act (PDSA) cycles. It is natural to want to jump in and fix the problem with a solution you think will work. However, it can save you much time and effort in the long run if you think more about the problem before diving into interventions. Here are some stages to proceed through when you want to start a QI project^3,4:

1. Forming the team: It is beneficial to involve key individuals at the beginning of the project to form a multidisciplinary team. Not only do you need everyone’s input due to their role being impacted by a project, but their participation can lead to increased staff engagement and satisfaction. Consider involving patients and families in your projects as well.
2. Establishing measures: Measures are essential to know whether your interventions lead to improvement. Establishing a baseline will also help your team understand the current state. There are different types of quality measures, most typically separated into outcome measures (the end result or impact on the patient/system), process measures (parts or steps that can lead to improving the outcome), and balancing measures (potential negative or unintended consequence of the project).
3. Setting aims: This stage addresses the Model for Improvement’s first question. Ideally, you should set a SMART aim, which is specific, measurable, actionable, realistic/relevant, and time-bound. An example is: we want to increase the percentage of children who receive five to seven days of antibiotics for skin and soft tissue infections from 30% to 70% in 12 months.
4. Selecting changes: Your multidisciplinary team should brainstorm multiple potential changes or interventions. You can then do a prioritization exercise to help choose what intervention or interventions to start with.
5. Testing changes: It is essential to start small before implementing something clinic-wide. PDSA cycles can be used at this stage to track your small-scale tests of change.
6. Implementing changes: Incorporating interventions into existing processes can be helpful. For example, if a staff member is already standardly asking every patient/family a question, it would likely be feasible to ask one more question at that same time. Furthermore, use technology if possible. Can forms be sent out ahead of the visit electronically or texted to the patient/family? Having data in the electronic health record can help with getting a report, as reviewing data is imperative to know whether your interventions are making a difference.
7. Spreading changes: Goals of QI projects include improving quality measure performance, but sustainability and spread should also be a priority at this stage. For example, if your project impacted only one patient population (i.e., based on diagnosis or age), you should consider implementing the same intervention in a different patient group or sharing it on a larger scale with other clinics.

QI tools can be used throughout this entire process, including a process map (understand the steps in a process), fishbone or cause and effect diagram (identify possible causes of the problem), Pareto diagram (identify the frequency of factors contributing to your problem), key driver diagram (identify factors and actions that could improve your aim), and PICK (possible-implement-challenge-kick out) chart (prioritize your ideas/interventions). Data should be reviewed over time, ideally on run charts or control charts, rather than just pre-/post-intervention. Some examples of these tools that you may find useful are available on the Quality Improvement Essentials Toolkit | Institute for Healthcare Improvement webpage.

Some additional things to consider include the effects on wellbeing of team members while implementing your project, which could be positive or negative depending on competing priorities, time and their interests. Checking in on wellbeing may mean including periodic surveys to ask team members how the changes have affected their workflow or satisfaction with their job. Furthermore, a health equity lens is helpful to have for all projects, especially in regard to how your project or interventions will impact disparities.⁵

QI work is never-ending but rewarding and the right thing to do to improve the care we provide all of our patients. By embracing QI and making it a priority for your entire team, you can and will make a difference in your patients’ lives. If you are interested in a QI project related to diagnostic or antibiotic stewardship and don’t know where to start, please reach out to AntimicrobialStewards@cmh.edu.

References:

1. McInerny TK, Sachdeva RC. The American Academy of Pediatrics and quality improvement. Acad Pediatrics. 2013;13:S7-8.
2. Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.2nd edition. Jossey-Bass Publishers; 2009. https://www.ihi.org/library/publications/improvement-guide-practical-approach-enhancing-organizational-performance
3. Institute for Healthcare Improvement. How to improve: Model for Improvement. Accessed June 18, 2025. https://www.ihi.org/library/model-for-improvement
4. Carroll AR, Smith CM, Frazier SB, Weiner JG, Johnson DP. Designing and conducting scholarly quality improvement: a practical guide for improvers everywhere. Hosp Pediatr. 2022;12:1-5.
5. Lion KC, Faro EZ, Coker TR. All quality improvement is health equity work: designing improvement to reduce disparities. Pediatrics. 2022;149:e2020045948E.