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Appaneal et al.
are important to improve antibiotic use in hospitals and to
slow the development of resistance.8 Multidisciplinary antibiotic stewardship programs are pivotal components in
ensuring patient safety and providing quality health care.
The Veterans Affairs (VA) is a leader in the implementation
and advancement of antibiotic stewardship programs
throughout the nation. In 2011, the VA developed the
National VA Antibiotic Stewardship Task Force to coordinate and guide efforts to improve antibiotic use and patient
safety throughout the many VA facilities nationally.9
Subsequently, in January 2014, the VA approved an
Antibiotic Stewardship Directive, which required each VA
facility to develop an antibiotic stewardship program and
identify a clinical provider and pharmacy champion.10
Despite the progressiveness and great strides the VA has
made, some medical centers still face barriers, such as limited financial and staff resources, to the implementation and
maintenance of successful comprehensive antibiotic stewardship programs, particularly in nonacute care settings.11,20
The CDC has outlined core elements to improve antibiotic
use in hospitals and nursing homes; however, these are
largely based off data from non-VA settings.12,13 It is not
well understood which factors assist or hinder the implementation and maintenance of these programs within the
VA. The objective of this project was to identify barriers and
facilitators to antibiotic stewardship within the medical centers of the VA New England Healthcare System (Veterans
Integrated Service Network [VISN] 1) through qualitative
interviews with pharmacists identified as champions or
pharmacists with responsibilities in making antibiotic recommendations within their medical center.

Methods
Approach and Theoretical Framework
Semi-structured telephone interviews were conducted to
obtain the in-depth views of pharmacists regarding the culture
of antibiotic use at their medical centers and on barriers and
facilitators to antibiotic stewardship. Culture of antibiotic use
was defined as the values, attitudes, and practices surrounding antibiotic use shared by the medical center staff. Culture
represents the way antibiotics are used and the attitudes of
staff about how antibiotics are used. The interview questions
and the analysis were guided by the framework used by Ploeg
et al14 to explore and understand individual (eg, a clinician's
knowledge and attitudes), organizational (eg, leadership support, teamwork, clinical champions), and environmental (eg,
support from national VA) factors influencing inappropriate
antibiotic use and antibiotic stewardship.

Settings and Participants
This project was conducted with pharmacists of the VA New
England Healthcare System, 1 of 21 VISNs within the US

Department of Veterans Affairs. At the time this project was
conducted, the VA New England Healthcare System consisted of 8 medical centers located throughout 6 states, which
provide inpatient and outpatient care to Veterans. In addition,
the VA New England Healthcare System had over 35
Community-Based Outpatient Clinics (CBOCs) and 6 longterm care facilities (known as community living centers or
CLCs) associated with the medical centers.
Pharmacists were selected for interviews through the use
of purposive sampling.15 The initial goal was to interview at
least 1 pharmacist from each medical center (which provide
a variety of acute, long-term, and outpatient care). Potential
pharmacist participants for interviews were identified
through communication with pharmacy directors at each of
the medical centers of interest. Pharmacy directors provided
e-mail and/or telephone contacts for potential participants,
who were either the identified pharmacy champion for medical centers with an established program or a pharmacist
with responsibilities in making antibiotic recommendations.
Some directors identified more than 1 pharmacist contact.
Introductory e-mails were sent to potential participants'
work e-mail addresses. Those wishing to participate were
instructed to reply and reminders were sent to those who did
not respond to the invitation. For those willing to participate, informed consent documents were obtained and a telephone interview was scheduled.

Instrument Development
Although each antibiotic stewardship program is different,
there are several core elements of antibiotic stewardship
that have been identified by the Infectious Diseases Society
of America (IDSA), CDC, and the VA.8,10,13,16 An interview
guide was developed based on these core antibiotic stewardship elements, including questions on leadership support, structure and team members, policies and actions to
support optimal antibiotic use, outcomes measures, reporting, and education. Interview questions were designed to be
semi-structured, including both specific questions and
open-ended questions. The instrument was pilot tested with
nonstudy pharmacists and questions were revised based on
feedback.

Data Collection and Analysis
All data were obtained through telephone interviews. One of
two interviewers conducted all the telephone interviews
(ML, TT). All interviews were audio recorded. Questions for
the interview were based on the interview guide, with additional probing questions asked based on participant
responses. All interviews were transcribed verbatim by one
investigator (HA). To review for quality and accuracy, the
original audio recordings were compared with transcripts.
All transcripts were read through, and then an initial code
manual was developed based on previous literature.11,14 The
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