Abstract TP32: Continuous Quality Improvement Implementation Across A Stroke Network

• Published in: Stroke (1970) Vol. 54; no. Suppl_1
• Main Authors: Zielke, Shelly, Brown, Harold E, Elkins, Kelley, Okong'o, Casey, Bellamy, Lisa M
• Format: Journal Article
• Language: English
• Published: 01.02.2023
• ISSN: 0039-2499; 1524-4628
• DOI: 10.1161/str.54.suppl_1.TP32

Abstract only Background and Purpose: One of the network missions is to improve quality of care through an evidence-based, standardized approach. In 2014 with 24 affiliate hospitals (25% certified stroke centers), a formalized continuous quality improvement process began and it continues through today with 37 affiliate hospitals (51% certified stroke centers). Methods: Over the years, the quality process has been enhanced to include additional abstraction training/support, individual data points for improved data analysis and a newly developed data report with built in logic and automatically populated graphs. Data is aggregated for network analysis and an annual scorecard is published that is utilized for benchmarking. Performance improvement (PI) goals are established as a network. Results: In 2014, 88% (21 of 24) affiliates submitted stroke data, compared to 91% (32 of 35) in 2022 fiscal year (Note: two affiliates are pending training). In 2022, 80% of non-certified stroke centers submitted data, compared to 100% for certified stroke centers. For Thrombolytic Therapy (STK-4), 79% compliance rate in 2014, compared to 89% in 2022; Thrombolytic Therapy (ASR-OP-1), 66% compliance rate in 2021, compared to 88% in 2022. For Dysphagia Screening (STK[PM]-7), 58% of the affiliates submitted data in 2014 with average of 92% compliance, compared to 89% in 2022 with an average of 87%. For Order Set Usage, in 2018 61% of the affiliates submitted data with an 87% compliance rate, compared to 89% of the affiliates submitted data with an 87% compliance rate in 2022. From 2018 to FY2022, the network had a 10% improvement in Door to Needle (≤ 60 minutes) from 66% compliance to 76%. Conclusions: The network showed improvement with the CQI program in: data submission rates, Door to Needle Time, and Thrombolytic Therapy. This is a success overall, particularly with the non-certified stroke centers. Though there are many confounding factors, this is in correlation with our focused improvement efforts such as individual follow-ups, data abstraction training, quarterly review of data, sharing best practices, updating program documents, monthly quality insights and education with affiliates.