Sustaining stroke registries: Controversy, challenge, and opportunity
Quality of Acute Stroke Care Improvement Framework for the Paul Coverdell National Acute Stroke Registry: Facilitating Policy and System Change at the Hospital Level

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Abstract

The Paul Coverdell National Acute Stroke Registry prototypes baseline data collection demonstrated a significant gap in the use of evidenced-based interventions. Barriers to the use of these interventions can be characterized as relating to lack of knowledge, attitudes, and ineffective behaviors and systems. Quality improvement programs can address these issues by providing didactic presentations to disseminate the science and peer interactions to address the lack of belief in the evidence, guidelines, and likelihood of improved patient outcomes. Even with knowledge and intention to provide evidenced-based care, the absence of effective systems is a significant behavioral barrier. A program for quality improvement that includes multidisciplinary teams of clinical and quality improvement professionals has been successfully used to carry out redesign of stroke care delivery systems. Teams are given a methodology to set goals, test ideas for system redesign, and implement those changes that can be successfully adapted to the hospital’s environment. Bringing teams from several hospitals together substantially accelerates the process by sharing examples of successful change and by providing strategies to support the behavior change necessary for the adoption of new systems. The participation of many hospitals also creates momentum for the adoption of change by demonstrating observable and successful improvement. Data collection and feedback are useful to demonstrate the need for change and evaluate the impact of system change, but improvement occurs very slowly without a quality improvement program. This quality improvement framework provides hospitals with the capacity and support to redesign systems, and has been shown to improve stroke care considerably, when coupled with an Internet-based decision support registry, and at a much more rapid pace than when hospitals use only the support registry.

Section snippets

Diagnosing Barriers to the Delivery of Care

The process of improving the quality of care relies on an accurate diagnosis of the barriers to improved care, and an appropriate “treatment plan” or quality improvement framework based on that diagnosis. Barriers to care can be classified into three general areas: knowledge, attitudes, and behavior (both individual and organizational).6 Knowledge of clinical trial results and guideline recommendations is a necessary prerequisite for delivering evidence-based care. Traditional physician

The System Redesign Process

The redesign of clinical care systems is the essence of quality improvement. It requires a strategy that employs clinical and quality improvement professionals involved in the care of stroke patients executing a continuous quality improvement framework, such as the Model for Improvement. While there are many approaches to clinical quality, this approach is based on continuous quality improvement tools developed by Shewhart, Deming, and Durand in the 1920s, and further refined for healthcare

Conclusion

Tools and processes to support data collection and the use of those data, as well as the necessary system and cultural changes needed to utilize the data, are critically dependent on a framework to support hospitals to incorporate these elements. Didactic presentations, hospital team sharing, and interactions among teams are all necessary components to accelerate the rate of improvement. Bringing together resources and expertise to support active quality- improvement programs from diverse

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    Copyright © 2006 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.