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A QUALITY IMPROVEMENT INITIATIVE: Systemic Changes Mark Quality Improvement Initiative in Stroke Care

Butcher, Lola

doi: 10.1097/01.NT.0000438153.20010.40
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As part of a system-wide effort to improve compliance with evidence-based guidelines for stroke care, Partners HealthCare, a multiple hospital network in Massachusetts, has initiated new protocols for the management and care of stroke patients who present to the emergency department. The article describes how they developed the initiatives and the promising results.

Most neurology quality improvement efforts around the country are initiated at a single hospital or within a given department, but Partners HealthCare, an integrated health care system based in Boston that includes academic medical centers and community hospitals, takes a much broader approach.

Partners HealthCare, founded when Massachusetts General Hospital and Brigham and Women's Hospital came together in 1994, drives quality improvement at the system level. More than a decade ago, leaders in cerebrovascular disease from each of six hospitals were recruited to participate in the Stroke Quality Leaders Program. Through that effort, neurologists at both teaching hospitals and community hospitals examined variations in practice among their facilities and started developing best practices and standards across the organization.

“We have been working together for years on projects like improving the timeliness of tPA delivery or adherence with quality benchmarks through participation in the Get With the Guidelines Stroke program,” said Lee H. Schwamm, MD, director of Stroke Services at Massachusetts General Hospital. More recently, he said, Partners has embarked on a system-wide Care Redesign initiative.



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One major redesign initiative is a standardized approach for managing transient ischemic attack (TIA) patients who present in the emergency department (ED), said Dr. Schwamm, who heads Partners' Care Redesign team for stroke.

Traditionally, many of those patients were admitted to the hospital because there was not a good process available to fully evaluate their condition in the ED. The quality improvement team created a structured evaluation tool that includes the data necessary to calculate a risk score for subsequent stroke.

“It's not a perfect tool, but it's gaining increasing acceptance across the country as a way to at least think about who is at highest risk for another event,” Dr. Schwamm said.

The new process calls for TIA patients to remain in the ED overnight on observation status to allow time for the appropriate diagnostics, including brain and blood vessel imaging, EKG monitoring, blood tests, and an evaluation by a neurologist either in person or in consultation with the ED physician. The team developed a schema for the appropriate sequencing of the imaging so each hospital follows the same pattern.

A review of the pre- and post-intervention data from three Partners hospitals showed a significant increase in compliance with the guidelines for TIA care and a significant reduction in admissions. The quality improvement team is analyzing data from 90-day follow-ups on those patients and intends to publish the results of its work.

“We think it's good for patients, it's good for the hospital, it saves money for the system, and it's very safe,” Dr. Schwamm said.

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Another major redesign initiative targets stroke patients treated with tissue plasminogen activator (tPA). Standard practice has been to admit those patients into an intensive care unit (ICU) so they can have continuous blood pressure monitoring and close nursing observation because of the relatively low risk of a brain hemorrhage.

An analysis of Partners' ICU use found that a huge number of patients spent one day in the ICU for this brief observation before being transferred to the neurology floor. The quality improvement team decided to create a “virtual” step-down unit that allows some mild stroke patients to receive intensive oversight — continuous blood pressure monitoring and a one-to-one nursing ratio — in a bed in the general neurology department rather than the ICU.

This offers two advantages, Dr. Schwamm said. Patients who avoid a day in the ICU progress more quickly to discharge, and neurology ICU beds are freed up for patients who are critically ill. “This is another way of trying to match the patient with the right environment and the right care team to the right patient, and minimize inefficiency,” he said.



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The first step for any quality improvement initiative is getting buy-in from the organization's top leaders, said Elizabeth Mort, MD, MPH, director of the Center for Quality and Safety at Partners. “You need to make the case in such a way that your senior management team not only approves of it, but [also] is promoting it,” Dr. Mort said. “This is hard work; it requires efforts across disciplines and resources.”

Foremost, senior management needs to ensure that physicians, nurses, and administrators have time freed up so they can work on specific quality improvement projects.

“To have the right person at the head of the table is critical,” Dr. Mort said. That should be a leader who has strong clinical credibility, high energy, and a desire to innovate.

Strong project management experience is critical, Dr. Schwamm added. And, he noted, the quality improvement team must have support from staff, as well as technology that allows data to be collected, analyzed, and reported in a timely fashion. Without that, team members cannot see whether their changes are working as expected and whether adjustments need to be made.

The Partners' Stroke Care Redesign team includes physicians, nurses, pharmacists, speech therapists, physical therapists, and data analysts. Redesign extends beyond the hospital, so the whole continuum of care for patients with a given condition needs to be included.

“Stroke care starts in the ED, so you need people from the ED and from radiology,” Dr. Mort said. “Then you need to bring people from rehab, home care, and primary care.”

“It's really important that you get the right people in the room. I can't say that enough,” Dr. Schwamm said, adding, the hierarchies that exist on the floor have to really disappear in these groups. “It can't be the doctors giving orders and everyone else is there just to carry them out. You really have to value the contribution of every member of the team equally, and you have to kind of lead more by inspiration than by decree.”

While clinicians want to improve patient care, they are often suspicious that the real motivation has to do with money. “There's always skepticism that this is just a cost-cutting maneuver wrapped in a ribbon,” Dr. Schwamm said.

While every hospital staff member sees waste, not everyone recognizes that it can lead to patient harm when, for example, a patient misses a medication because he or she is taken for a needless exam.

He encourages staff to focus on how they can improve patient care by being good financial stewards. “It's not about just wringing costs out of the system. It's really about being smarter about how we spend the resources,” he said. “That dialogue has to be constantly present.”

This article is part of a continuing series that focuses on neurology quality improvement initiatives taking place nationwide. The complete archive of articles, podcasts, and videos from the series is available here:

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•. Initiatives of the Partners HealthCare Redesign Team:
    •. AAN resources on quality measures:
      •. Harvard Fellowship on Patient Safety:
        © 2013 American Academy of Neurology