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QUERI Partnership to Help Providers Improve Acute Stroke Care for Veterans

Part of the mission of the Precision Monitoring to Transform Care (PRIS-M) QUERI program is to identify implementation strategies that activate VA providers, leaders, and Veterans to use data to transform care. Partly funded through QUERI, and supported by VA CASE staff, a recent clustered randomized study evaluated external facilitation as an implementation strategy alongside of an acute stroke quality improvement VA collaborative to determine whether quality improvement training plus indicator data feedback was more effective than indicator feedback alone in improving inpatient stroke indicators. Facilitation is an implementation strategy that may include external facilitators (e.g., outside of the local site) who help guide the internal facilitators (e.g., inside the local site) to implement evidence based processes. Use of data to audit and report feedback on quality performance is another implementation strategy to improve quality and was included in this bundled acute stroke quality improvement intervention. Results showed that while external facilitation quality improvement programs may quickly boost performance, their effects may vary by indicator and may not sustain over time (Williams, et al. 2015).

Moreover, a qualitative study of the facilitation demonstrated that the external facilitators viewed their role as empowering the clinical teams to take ownership of the process changes at the clinical sites to improve their performance quality. Core facilitation elements identified were related to communication, relationship building, methods training, monitoring performance over time, and facilitating team-based problem solving (Bidassie, et al., 2015).

In the following Q&A, Victor Sung, MD, who was the founding Director of the Birmingham VA Medical Center Primary Stroke Center and who currently serves as Director of the Birmingham VA Medical Center Deep Brain Stimulation Program, discusses how QUERI investigators' work on external facilitation in the acute stroke collaborative helped him improve acute stroke care for Veterans.

How did your collaboration with QUERI come about?

Given our geographic position within the "Stroke Belt" (region in the southeastern U.S. with an unusually high incidence of stroke) and relatively high volume of stroke admissions, Birmingham VAMC was identified early as a potential site for the INSPIRE project developed by Dr. Linda Williams. [The Intervention for Stroke Improvement Using Redesign Engineering (INSPIRE) is a VA quality improvement intervention that compared implementation facilitation plus data feedback to data feedback alone across 11 VAMCs.] I had recently completed a VA Quality Scholars Fellowship and, despite my lack of stroke fellowship training, was tasked with the project of improving stroke care at BVAMC. Through INSPIRE, I was able to learn more about stroke quality measures.

Dr. Williams is one of PRIS-M's co-Principal Investigators, along with Drs. Dawn Bravata, Teresa Damush, and Salomeh Keyhani.

How did QUERI's PRIS-M help you implement LEAN methodology into your practice?

In addition to site-specific data on our performance on key measures, QUERI researchers provided me with much needed analytic support and tools to implement LEAN methodology in improving stroke care as taught by VA-CASE Systems Redesign Engineers during the Stroke Collaborative. I assembled a multidisciplinary team with members from various positions and departments. Together we analyzed existing processes of stroke care and developed new plans to improve those processes by streamlining/eliminating waste and continuously reassessing the processes. Examples include redesign of Code Stroke and tPA administration processes, development of stroke specific order sets (emergency department, medical/surgical admission, and ICU post-tPA care), dysphagia screening, and neurological checks. [Tissue plasminogen activator, or tPA, works by dissolving a blood clot in the brain and improving blood flow to that part of the brain being deprived of blood.]

What is the expected impact of your work with QUERI researchers on acute stroke care for Veterans?

There were many hospital-wide improvements in care that resulted from our work to improve stroke care processes. For example, in order to be able to administer tPA at all times for acute stroke, we successfully lobbied for additional resources to provide 24-hour STAT CT availability, which was never previously offered at Birmingham VAMC. This improved acute care for all medical conditions and gained us allies specifically in the emergency department and ICU. We are now one of a small number VA Primary Stroke Centers in the country and have increased the number of tPA administrations by five fold in the past three years. This phenomenal success is owed directly to our collaboration with QUERI researchers.