Healthcare Engineering Methods Can Improve Stroke Care Quality

Williams LS, Woodward-Hagg H, Daggett V, Plue LD, Damush TM, Bravata DM. Healthcare Engineering Methods Can Improve Stroke Care Quality. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2010 Feb 22; 41:e288.

Background/Objectives: Inpatient stroke care quality can be assessed by measurement of key process indicators. How quality improvement programs can be most effectively structured to improve stroke care is not well described. The objectives of this pilot project were to: 1) develop and implement a stroke quality improvement program based on System Redesign/Lean Six Sigma principles; and 2) to evaluate its impact on inpatient stroke care quality. Methods: Working with Department of Veterans Affairs clinicians and managers, we identified stroke champions and teams at all seven Veterans Integrated Service Network 11 facilities. Using a collaborative model we developed a training program for stroke teams that included in-person and web-based sessions covering System Redesign and Lean improvement Methods. Sites selected two Joint Commission stroke quality indicators on which to focus: dysphagia screening before oral intake and discharge on cholesterol lowering medication. Teams attended a 2-day collaborative in which they completed System Redesign/Lean training, shared pre-work including stroke indicator data collection and stroke system of care maps for each site, developed a standardized electronic stroke order set, and developed site-specific initial Plan-Do-Study-Act (PDSA) cycles for the two indicators. Teams participated in monthly group and site-specific calls with system redesign facilitators for six months to help address site-specific barriers to improvements. Facilitators monitored the types of improvement strategies used, number of PDSA cycles completed, and team participation in calls. Data on the two indicators from 2007 were compared to six months post-intervention data (June-November 2008) using paired t-tests. Results: Within six months of the collaborative, six of the seven sites had effectively implemented the electronic stroke admission order set. Health IT interventions (e.g. electronic orders/reminders) and provider training were the most commonly used improvement strategies. Sites completed a median (range) of 4 (1-15) PDSA cycles and attended an average of 64% of coaching calls. Performance improved from a mean (range) of 26% (0-100%) to 48% (14 100%) on the dysphagia indicator (p 0.23) and from 83% (67-100%) to 87% (50 100%) on the cholesterol indicator (p 0.62). After six months, three sites had spread the System Redesign methodology to address other non-stroke improvement challenges. Conclusion: System Redesign/Lean methodology can be successfully integrated into a collaborative-based stroke quality improvement intervention. The intervention may be effective for improving performance although small sample size (seven sites) limited our power to detect statistically significant differences. This intervention will be tested in a larger randomized trial to be conducted at 14 VA facilities in 2010.