Shared Team Efforts Leading to Adherence Results (STELAR)– trial of a quality improvement program in acute stroke care

The STELAR program is a complex intervention (i.e. has multiple and interacting parts). The STELAR program is designed to be delivered in four discrete stages: pre-workshop survey, two facilitated workshops and then ongoing support by the program team. The program is based on a multi-component quality improvement (knowledge translation) intervention that includes external facilitation using audit and feedback; educational meetings with action planning; and use of local opinion leaders. Each site had a ‘change champion’ appointed to ensure local responsibility and commitment to the action plan and agreed strategies. Local opinion leaders deliver the educational component of the face-to-face workshop as there is strong evidence that local opinion leaders can influence rapid uptake of evidence. The hospital participants include some or all of the following staff: medical, nursing, allied health, pharmacy, executives and quality managers. Stage 1: Pre-workshop survey: To gain a better understanding of current practice regarding processes of care, staff involved in providing acute stroke care from participating hospitals are asked to complete a pre-workshop survey. The questionnaire is designed to identify potential barriers, and enablers to providing “best practice” stroke care. It covers a broad range of hospital practices including: current systems, practice protocols, team structures, culture and roles. Information is then collated to identify potential clinical aspects of care for discussion during the first workshop. The survey is distributed electronically by the external facilitator approximately two weeks prior to Workshop 1 and remains open for one week. Stage 2: Workshop 1 (data feed back) is an hour-long workshop presented as a videoconference to minimize travel costs and promote reach, especially to regional sites. The workshop is presented by the external facilitator approximately one week after the pre-workshop survey has been conducted. The aim of this workshop is to review the survey results and local clinical performance data obtained from the Australian Stroke Clinical Registry (AuSCR) against national benchmarks. Participants are asked to consider local barriers and enablers to providing ‘best-practice' care and the most important policies, team roles, and resources that could be modified. Potential opportunities for interventions, that are deemed feasible by the participants, are discussed for consideration and categorised into low, medium and high priority. The information from this workshop is then used to tailor the content of Workshop 2 which includes tailored education and evidence-informed action planning (see below). Potential leaders within the participant group are also identified to assist with Workshop 2. Stage 3: Workshop 2 (~ 2 weeks after Workshop 1), includes tailored education and evidence-informed action planning that is conducted as a two-hour face-to-face meeting at the local site with an external facilitator trained in knowledge translation methods. The education component is presented by a ‘local opinion leader’ or other content expert. Then the external facilitator provides a summary of the local gaps between current practices and 'best practice' that were identified from the initial review of the AuSCR data during Workshop 1. A summary of the Workshop 1 discussion of perceived barriers and enablers is also presented. The external facilitator then works with the participants to draft a local action plan to be implemented by the clinicians responsible for these activities, which targets the identified ‘mission critical’ modifiable barriers related to the processes of care to be improved. A ‘change champion’ is appointed. The actions plans are to be implemented with a view to maximizing existing processes and activities to improve efficiencies within sites, rather than increasing staff workloads. At the end of the workshop, a survey is completed by all participants to gauge their satisfaction with the workshop. Stage 4: The 'change champion' or other designated hospital contact is provided with ongoing support by the external facilitator for a minimum two month period following Workshop 2 in order to implement the action plans and were encouraged to meet the agreed timelines and goals. Support includes regular email contact and phone calls with the staff responsible for leading work on the action plan. The support provided to all hospitals is recorded by the Facilitator on the STELAR program 'support activity log'. Regular local hospital performance monitoring regarding adherence to the selected care processes, using AuSCR ‘live reports’, is also encouraged by the external facilitator as part of encouraging regular audit and feedback cycle reviews.