Lessons Learned in the Process of Stroke Quality Management: Revised tools and strategies in a follow-up study
Objectives Written care protocols and quality improvement efforts have recently been included in published guidelines on care of the ischemic stroke patient. We describe revisions to the quality management process that resulted in increased protocol use at a 469-bed medical school affiliate private hospital. Methods An earlier clinical pathway for ischemic stroke was ineffectively implemented as shown by pathway use in less than half of appropriate cases. A multidisciplinary team addressed barriers identified in that early experience to modify strategies in the development of a new set of quality management tools (QMT) for ischemic stroke. The revised QMT included: standing orders, clinical pathway, NIH Stroke Scale flow sheet, diagnostic summary form, and variance tracking tool. QMT use rates were calculated by medical record abstraction during a 3-month pilot study and physician and nurse usage rates determined. Factors contributing to QMT usage were analyzed. Results Twenty-eight ischemic stroke patients were admitted to the pilot unit during the study. Usage rates for components of the QMT driven by physicians were: standing orders 93%; IV tPA standing orders 100%; and diagnostic summary form 46%. Nurse related QMT usage was: clinical pathway 96%; NIH Stroke Scale flow sheet 75%; and variance tracking tool 75%. Key strategies that contributed to improved implementation were: 1) early involvement and continuous communication between the expanded multidisciplinary team, staff nurses and physicians 2) empowerment of nurses through NIH Stroke Scale training 3) perception of mutual accountability between nurses and physicians through use of QMT documents 4) clearly defined administrative directives. Conclusion Effective implementation of quality management protocols for ischemic stroke requires active participation of related disciplines at working levels, clear administrative support, and mutual accountability of physicians and nurses. Continuous critical appraisal of the process can afford eventual strategic solutions.