Despite many advances in prevention and acute management of stroke, there is wide variation in the quality of care provided to veteran stroke survivors. The Stroke QUERI developed two new health information and communication strategies in an attempt to help improve disparities in quality of care: 1) Stroke Quality Improvement Network (SQUINT); and 2) web-based stroke quality improvement toolkit. SQUINT includes VA stroke thought leaders who exchange quality improvement strategies and best practices via monthly conference calls. The web-based toolkit, which is located on the QUERI website, was created to provide evidence-based resources and materials (e.g., a series of stroke quality indicators) for VA providers who are interested in improving stroke care.
The specific aims of this RRP were two-fold: 1) to evaluate the strengths and weaknesses of the SQUINT and to identify the factors that make it an effective network to promote best practices in VA stroke care; and 2) to evaluate the web-based Stroke QUERI toolkit to determine the most useful aspects (i.e., what are the study participants' perceptions of the characteristics of the toolkit that are considered to be the most useful and those that require improvement?).
Study participants were identified and selected through purposive sampling techniques of both SQUINT and non-SQUINT members, targeting those from both high and low volume stroke facilities. A list of potential respondents was generated by the SQUINT leaders and given to our research team in order to recruit network participants. We expanded our sample using a snowball sampling method. During the interview we asked the SQUINT participants the following question: "We wish to interview as study participants clinicians within the VA who care for veterans with stroke and who are not currently involved in SQUINT. Please tell me who you believe should be asked to be interviewed?" This question then provided us a list of names from which we could recruit respondents. In order to achieve the maximum variation possible, we also employed targeted purposive sampling to identify prospective participants by region and stroke volume. Semi-structured telephone interviews were performed with 48 VA clinicians and managers throughout VHA. Grounded theory methodology was used to develop and integrate core categories that emerged from the data. The coding framework was developed with a starter list of codes used by each of our team members to code the same randomly selected interview. Through this process we identified, defined and operationalized core categories. These categories were then used to examine congruent, divergent and conflicting themes.
Of the 48 respondents, 24 were women, 38 were non-SQUINT members, 33 had not previously used the toolkit, and one-third were from low volume stroke VHA facilities. With reference to the SQUINT, 70% found that the calls were interactive. Four themes emerged regarding the strengths of SQUINT, including administrative support (for participating on calls), applicability (information on calls applies to respondent), focus (type of information on the call), and dissemination (how information about the call itself and its topics are shared). SQUINT members believed that the call should be a teaching forum with expert instruction with a focus on sharing and transferring knowledge. More specifically, this knowledge transfer should include the following mechanisms: 1) illustrating the successes and challenges to implementation; 2) sharing research pertinent to clinical practice; and 3) incorporating a broader spectrum of topics than currently exist on the call. Three additional themes were identified that could be characterized as areas of improvement: 1) dissemination (too few people were aware of the call; no centralized web portal where agendas, and Powerpoint presentations are posted); 2) size of group/attendance (too few people consistently attend to have an impact, thereby limiting effectiveness; not a diverse enough group); and 3) presentation of call (wider range of options should be employed to advertise the call).
Major themes for the evaluation of the toolkit included applicability (information applies to and fills a perceived need of the respondent), format (structure of information), and dissemination (how information is spread). With reference to the applicability theme, the toolkit was viewed as informative, well-organized, and comprehensive. Regarding the format theme, respondents noted that they felt the site was easy to use and easy to navigate. However, respondents wanted more information related to rehabilitation, TPA, and post-discharge care. Existing toolkit users identified areas of the site that they utilized most often; those previously unaware of its existence found the prospect of having a "one stop shop" at which to find stroke care information across the continuum of care exciting. Dissemination of knowledge regarding the existence of the toolkit remains a barrier to wider adoption for VHA employees. Both users and non-users of the toolkit identified limited knowledge of its availability to a broader base of clinicians and administrators as a significant barrier to use.
As VA clinicians seek to improve the quality of stroke care, the SQUINT network can provide helpful resources for them within a community of VA clinicians who are similarly engaged in stroke quality improvement activities. The interviews from the study participants provide important data on what key features of the SQUINT monthly calls are informative and what topics need to be discussed with the ultimate goal of improving stroke quality at VHA facilities. Toolkit users noted a number of specific components they accessed and implemented locally to improve the quality of stroke care. For example, many respondents cited using the dysphagia screening tool, the NIH stroke scale, and smoking cessation information for patients at their facilities. Some study respondents led initiatives to implement actual toolkit components at their local VA facilities. After using the toolkit, one respondent notified their facility leadership to put into practice online order sets to create tools in their local CPRS system. This same individual held an educational training for lead stakeholders in order to facilitate dissemination and use of the new tools across the facility.
- Sternke E, Burrus N, Daggett VS, Plue LD, Carlson K, Hershey L, Chumbler NR. Improving knowledge and information sharing to promote best practices in stroke care: Evaluation of the VA Stroke QUERI Toolkit. International Journal of Reliable and Quality E-Healthcare. 2013 Feb 1; 2(1):11-25.