Perspectives in Medicine (2012) 1, 7376

Bartels E, Bartels S, Poppert H (Editors):

New Trends in Neurosonology and Cerebral Hemodynamics an Update.
Perspectives in Medicine (2012) 1, 7376

journal homepage: www.elsevier.com/locate/permed

Act on Stroke Optimization of clinical processes

and workow for stroke diagnosis and treatment
Bernd M. Hofmann a,, Udo Zikeli a, E. Bernd Ringelstein b

a
Siemens AG, Healthcare Sector, Erlangen, Germany
b
Department of Neurology, University of Mnster, Mnster, Germany

KEYWORDS Summary In the Helsingborg Declaration the continuum of care consisting of pre-, intra- and
Stroke; posthospital organization of stroke services combined with evaluation of outcome measures and
Process optimization; dedicated quality assessments was considered as key for best outcome. Despite the evidence
Outcome; of such measures there are still striking disparities in organized stroke care all over Europe.
Quality of care Aim of this paper is to describe current concepts used for process optimization in stroke care
and to evaluate if methodologies used in industry provide additional benet in order to address
this issue.
We describe the transfer of a commonly accepted industrial maturity model to stroke care
addressing structural, process and outcome quality. Moreover, this tool can be used to compare
different stroke services and provides valuable information for their optimization by transfer-
ring best practices from best in class services as well as for prioritization of improvement
measures.
2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

Introduction
The burden of stroke is high due to its high incidence, mor-
tality and morbidity [14]. In order to reduce this burden,
the Helsingborg Declaration has postulated the present and
future European goals of stroke care. As a major component
of the chain of care, stroke unit treatment was considered
essential, and was therefore nominated the backbone of
integrated stroke services. This is clear scientic evidence
that outcomes in stroke patients managed in dedicated
stroke units are better than those managed in general
Corresponding author at: Siemens AG Healthcare Sector, H CX
CRM-VA HCC NEURO, Allee am Roethelheimpark 3a, 91058 Erlangen,
Germany. Tel.: +49 9131843374.
E-mail address: bernd.m.hofmann@siemens.com
(B.M. Hofmann).
medical wards [5]. Within one year, stroke unit care leads
to signicantly reduced death or poor outcome [6]. As a
logical consequence, basic requirements were dened for
successful stroke unit care, which are multi-professional
team approach, acute treatment combined with early mobi-
lization and rehabilitation, as well as an exclusive admission
of patients with stroke syndromes to that ward [6]. More-
over, the continuum of stroke care was considered as the key
for best outcome consisting of prehospital, intrahospital and
posthospital organization of stroke services, also considering
secondary prevention, as well as step down rehabilitation
after stroke, including measures for evaluation of stroke out-
come and dedicated quality assessment [5]. However, there
are still striking disparities in organized stroke unit care all
over Europe [710], and no generally accepted denition
of a stroke unit in terms of state-of-the-art require-
ments of facilities, personal and processes does exist. In
order to solve this problem, there are constraints in the

2211-968X 2012 Elsevier GmbH. Open access under CC BY-NC-ND license.

http://dx.doi.org/10.1016/j.permed.2012.03.007
74
European Stroke Organization to dene a terminology and
shared requirements on a European stroke unit (Ringelstein,
personal communication). Hospitals should be encouraged
to compete for the best solution, and the most engaged
ones should serve as guides and frontiers for stroke unit
development. In addition, a recent consensus paper [11]
requested to improve and develop the systems of interna-
tional cooperation in stroke research, and to implement key
elements into clinical pathways which are identied to be
benecial in stroke treatment. Moreover, it was postulated
to identify and implement standardized clinical and surro-
gate assessments and to accelerate the capacity to address
unmet needs. This could be done by scanning other areas
of science in order to enhance the likelihood of generating
new ideas and concepts.
In industries the optimization of infrastructure and pro-
cesses and the determination of so-called key performance
indicators in order to proof the efcacy of improvement
measures is standard since many years. By extending the
above stroke-related requests, the aim of this paper is to
evaluate whether concepts can be transferred from indus-
try to healthcare in order to support optimization processes
in stroke unit care.
Methodology
In a rst step, current concepts used worldwide for the opti-
mization of stroke treatment were analyzed regarding their
efcacy. Possible reasons for suboptimal results from these
measures were extracted. In a second step, generally avail-
able methodologies for process optimization used in industry
were analyzed with respect to their transfer into health-
care systems. In particular, we analyzed which requirements
have to be met by those methodologies in order to be trans-
ferred successfully, how the relevant clinical and scientic
content could be identied and implemented as basis for
optimization. We also elaborated how clinical and scientic
evidence of the content and improvement potentials could
be ensured.
Results
Clinical guidelines were found to be the most important
sources for optimizing stroke care and have to be obeyed
in all circumstances. This is due to their scientic and clin-
ical evidence. Some hospitals, however, do not support to
implement them into clinical routine in an effective matter
jeopardizing their impact. Programs monitoring guideline
adherence are addressing this issue but do not provide
enough support for systematic implementation.
Several national certication programs are based on
guidelines, but rather assess the structural quality of a
stroke service than the process and the improvement of
treatment quality and clinical outcome; although it has been
shown in a recent publication that certication efforts can
lead to better clinical outcome [12]. A new certication
program proposed by the European Stroke Organization will
overcome some of the above mentioned shortages and will
monitor outcome parameters. Guidance for hospitals willing
to improve their processes, however, will still be required
B.M. Hofmann et al.
for a sufcient implementation of clinical guidelines into
routine processes.
The effect of programs measuring quality or performance
indicators is still under debate [13] and they often focus
too much on the formal fulllment of requirements like
prescription and dispensation of anticoagulants, or statins
as well as the early rehabilitation assessment, but are not
helpful in dening how to increase the performance level
[14]. The underlying processes to ensure the fulllment of
given requirements and regulations have to be dened and
implemented by the hospital staff.
Quality management systems like ISO, EFQM and TQM
evaluate structures and processes but do not assess the
related outcome. They were rst used in industry and trans-
ferred to healthcare systems thereafter. The necessity that
an individual organization has to dene its own quality
goals, as well as the processes to achieve them, could be
considered as a weakness. Moreover, those programs are
addressing entire hospitals rather than specic diseases or
functional units.
Pure industrial process optimization programs are
addressing processes without considering best practices
from other organizations. After dening their own quality
goals, the processes to achieve them have to be developed
by the organization itself.
Finally, process consulting is helpful in order to solve
individual problems, and best practice transfer is the basis
of this type of optimization. Most consulting projects are
very long lasting, however, and put a high burden of the
organization regarding human resources.
According to our experience, all above-mentioned pro-
grams are addressing relevant parts of clinical process
optimization in stroke care. None of them provides a holis-
tic solution, however. Reviewing the literature, Donabedian
[15] has dened three different qualities in medical care
describing the basis for optimization in stroke care. The
structural quality is covered by guideline adherence. In this
context it is important that the guidelines are dened by
the medical societies and based on clinical and scientic
evidence. However, the guidelines have to be implemented
into clinical processes resulting in a positive impact on pro-
cess quality. By combining both efforts, the quality of care
is expected to increase but this effect has to be monitored
in order the proof outcome quality.
In order to address these three qualities, a methodol-
ogy for process optimization in stroke care has to include
all the relevant clinical guidelines and to reect the orga-
nizational structure which is dened by specic guidelines.
Moreover, such a methodology has to have the capability
to support optimization of clinical processes addressed by
management consulting tools. Additionally, transfer of best
practices will be helpful in achieving this goal. Our focus
should be on support processes as well, which contributes
in improving the process quality, e.g. providing optimized
imaging infrastructure. An essential part is also to measure
quality parameters thus addressing structural, procedural
and outcome performance indicators.
Keeping all these requirements in mind, so called
process maturity models seem to best meet our needs.
They are generally accepted in software industry or aero-
nautics. The calculation of a providers maturity level which
is an integral part allows even benchmarking between
Act on Stroke Optimization of clinical processes and workow for stroke diagnosis and treatment
hospitals and can be used to dene best practices and to
facilitate their transfer. Thereafter, Process improvements
can be derived from those best practices best practices.
Combining this methodology with intelligent approaches for
simulation, prioritization between different improvement
measures becomes possible.
Because industrial maturity models are based on a virtual
best practice combination composed of real-world practice
elements from various organizations, the question arises
how this principle can be applied to healthcare systems.
In our clinical maturity model named Act on Stroke,
we implemented all relevant clinical guidelines, as well
as latest results in stroke research based on clinical and
scientic evidence. We performed best practice visits in
institutions well known for their excellent stroke service and
included experience from more than 400 consulting projects
in healthcare. In the end, our data resulted in a clinical
maturity model addressing optimized stroke care.
Best practice visits and pilot projects in hospitals with
experienced department heads in stroke care were per-
formed and provided further promising results which again
were introduced into the methodology. Indeed, heads of the
departments certied that all relevant strengths and weak-
nesses of their services have been identied by using this
clinical maturity model. Proposals for process improvements
have also been helpful to them. Meanwhile, the rst regular
projects have been carried out successfully, and the results
are currently in preparation for publication.
Discussion
For more than 40 years, maturity models have been helpful
in software industry in order to improve processes and, as a
consequence, leading to better outcomes. This principle has
been used for the optimization of clinical processes, as well.
Healthcare is dealing with human beings, however, has and
the applicability of industrial processes had to be discussed
carefully.
The content for the denition of the virtual best prac-
tice is of clinical and scientic relevance, and it has to be
specied who denes it. From our point of view this should
be done as a joint venture by experienced stroke physicians
in cooperation with specialists experienced in process opti-
mization. Care has to be taken that the patients needs and
the adherence to clinical guidelines are the most important
and that the maturity level is respecting this. A not yet fully
solved problem is how to deal with improvement measures
to processes or requirements not yet based on clinical evi-
dence. It has been shown [16,17] that improvement of key
measures lead to better outcome even if they are as such
not based on large randomized trials. The fact that some
requirements are based on clinical evidence while others are
not, has to be met by the particular methodology of Act on
Stroke and a solution for this issue has been implemented.
In contrast to the linear nature of industrial processes,
processes in healthcare are more complex and can be inu-
enced by hard to control parameters. For this reason, it is
not always possible to directly assess the impact of a single
optimization measure, because a given factor inuencing a
certain process does not do so in different hospitals. As a
consequence, the efcacy of our model has to be proven
75
rst in pilot projects, in particular with respect to clinical
outcomes.
The authors have developed a clinical maturity model
providing answers to the above mentioned questions. They
carried out several pilot projects for proof of principle
and with the intention of individual process optimiza-
tion. A detailed description of the methodology and the
encouraging results of the rst projects are currently under
evaluation and will be published in a separate paper.
Conclusion
Industry can provide useful tools for supporting the opti-
mization of quality of care and outcome in stroke treatment.
This can be achieved by a standardized and unbiased assess-
ment of hospital infrastructure, improved processes of
stroke care and comparison of outcome performance from
best in class services.
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