By Stephen Spotswood

INDIANAPOLIS, IN--While stroke is a debilitating condition that VA physicians deal with regularly, only very recently has there been a way for VA facilities to judge the quality of their stroke treatment. 

A joint endeavor between VA’s Office of Quality and Performance (OQP) and the VA Stroke Quality Enhancement Research Initiative (QUERI), the Stroke Special Project fills a large gap in VA’s knowledge of its clinical practices and sets the groundwork for considerable improvements in the future.

A process for assessing of VA’s stroke care is at least eight years in the making. When VA formed the Stroke QUERI in 2004, researchers and clinicians realized the lack of a set of measurable performance measures was a fundamental obstacle for the healthcare agency if it wanted to move forward.

The adaptive physical activity program for chronic strokes survivors at VA Maryland Exercise and Robotics Center of Excellence. Photo from VA website.

“It was a high volume, high impact disease condition, which is why VA formed a QUERI around it to improve care,” explained Linda Williams, MD, research coordinator for VA’s Stroke QUERI. “We began looking at how to measure quality of care and realized we were going to have to do some kind of assessment.”

Over the next few years, a partnership began to form between the VA staff in charge of operations and measurement at OQP in VA and clinical leadership. Between 2007 and 2009, OQP assembled a multidisciplinary team of stakeholders in stroke care. The goal was not just to gather data for publication but also to drive improvement at VA facilities.

Beginning in late 2009, the team started gathering data, beginning with existing measures proposed by national bodies, such as DoD and the American Heart Association, then to existing VA measures. The result was a list of 14 indicators to evaluate quality of inpatient stroke care.

OQP contracted an outside company to perform data collection. Over several months, 90 trained chart-reviewers looked at a sample of 5,000 veterans who were admitted for ischemic stroke in FY 2007 at 131 VA facilities.

Forums were convened so officials at VA facilities could ask questions about the data and the results. A final report went out at the end of 2009 describing VA’s national performance across all 14 measures.

Room for Improvement

As the results of the review became available, one message was clear: VA was doing very well in a number of areas of stoke care, but there was room for improvement, especially in the acute stroke period.

“This led the group to start thinking about what we could do from an operational standpoint,” Williams said. “VA formed an Acute Stroke Task Force at the national level, which released a directive in November 2011.”

The most striking part of the directive was that each VA facility was asked to self-designate their ability to provide acute-stroke care. Were they able to give acute thrombolysis for stroke 24 hours a day? If they were able to provide it only part of the time, they were designated a VA limited hours stroke center. If they were not capable at all, the facility needed to codify a system to send the veteran to a facility that could provide it.

“If you’re a facility that is capable of giving acute thrombolysis, you have to formally put together a stroke team, a pathway for acute therapy, a location where patients are admitted [and provide] additional training for staff,” Williams said. “And the requirements for education are not only for staff, but also for veterans.”

The release of the final report in 2009  also was accompanied by resources that facilities could use to improve stroke care. That included an online toolkit with ways to improve all 14 quality measures, and the creation of the Stroke Quality Improvement Network (SQUINT). Supported by VA Central Office, SQUINT is comprised of stroke experts from around VA that can provide advice and support to VA facilities.

“Eight one-hour sessions of stroke training were provided to every facility in VA,” Williams said. “The SQUINT group has been very important in following up on that. Since the training happened, so many people have been calling in to SQUINT that we don’t have enough phone lines.”