Better Care for stroke patients through collaboration by Santeon

BETTER CARE FOR

STROKE PATIENTS THROUGH COLLABORATION

CARE FOR IMPROVEMENT

2018

EDITION

CONTENTS

' IT IS DIFFICULT TO WORK OUT IN A GYM OR AT A REGULAR ASSOCIATION, THERE ARE TOO MANY OTHER IMPULSES. YOU WOULDN’T NOTICE WHEN YOU SEE ME BUT THAT SOMETIMES MAKES IT DIFFICULT BECAUSE I WILL GET OVERSTIMULATED MORE QUICKLY.'

FOREWORD

6 CHAPTER 1 6 FASTER IMPROVEMENT IN A STRUCTURED IMPROVEMENT CYCLE 6 CARE IMPROVEMENT BASED ON VBHC PRINCIPLES 6 DATA COLLECTION AND DISCUSSION 7 SHARING OUTCOMES AND RESULTS 7 EXPERTISE 8 IMPROVEMENT CYCLES FOR VARIOUS CONDITIONS 9 CHAPTER 2 9 WORKING WITH THE STROKE IMPROVEMENT TEAM 10 ABOUT STROKES 10 THE STROKE IMPROVEMENT TEAMS 10 PATIENT GROUP, TREATMENT OPTIONS, AND SCORECARD 18 CHAPTER 3 18 RESULTS AND IMPROVEMENTS OF STROKE CARE 18 OUTCOMES 24 COSTS 30 PROCESS 34

WHAT COMES NEXT

35 36 38 38

ANNEXES ANNEX 1: IMPROVEMENT TEAMS INVOLVED ANNEX 2: EXPERTS COLOPHON

TREES VULTO, PATIENT ST. ANTONIUS

PREFACE

eal improvements to R care In the past year and a half, Santeon hospitals have worked together to make the outcomes and costs of care for cerebrovascular accidents (strokes) more transparent, shared these with each other and made improvements. We would like to share the first results in this publication.

' BEHAVIOURAL CHANGE STARTS WITH AWARENESS, AND THESE FIGURES ACHIEVE THAT.'

Medical Leader Sander van Schaik from OLVG is a neurologist and data-analyst combined. ‘I am very interested in structured analysis of data which we, as caregivers, often generate on a daily basis without being aware of it. It occurred to me already during my training as a neurologist that a great deal of the data that we provide for the different quality registrations can hardly be used in an internal quality cycle. This is despite the fact that feedback based on this data can visibly improve the quality of care and add more value to our care for stroke patients. The scope of the Santeon Value-Based Healthcare (VBHC) programme is unique in its kind and makes it possible to go even deeper into the data in order to identify potential for improvement. By presenting this data in an insightful way, we get a much better picture of our performance as care providers when it comes to care for stroke patients. We go further than a median or average in this and sometimes we find that certain assumptions that have existed for a long time are incorrect. A good example of this can be found in this report. In times of high demand for care and scarce care, initiatives such as the Santeon VBHC programme will help to ensure that we will be able to use our limited resources more efficiently. This programme also offers us the platform within Santeon to talk with colleagues about innovations in care, for example in the field of supplementary diagnostics and outcome measurement. Because of the wealth of data that is generated in this programme, there are also opportunities in the field of scientific research, which we will explore in the near future. You understand that this mini-data mining project is one of my favourite 'side jobs' in addition to my work in patient care.' Sander van Schaik, Medical Leader Stroke Neurologist at OLVG and Zaans Medical Centre

SANDER VAN SCHAIK, NEUROLOGIST OLVG 4

CHAPTER 1

Faster improvement in a structured improvement cycle

Seven top clinical hospitals collaborate closely under the name of 'Santeon’ in order to improve care. This collaboration is unique because the professionals get to take a look 'behind the scenes' at each other's hospitals. They compare the results of treatment and learn from each other to provide even better care.

the basis for the data collection and analyses. The underlying principles for the collection of data are relevance and feasibility. For example, no new data is collected, but existing data is used, which can often be automatically retrieved from the various source systems (e.g. the Electronic Patient Dossier (EPD) or Dutch Acute Stroke Audit (DASA)).

Value-Based Healthcare (VBHC) improvement cycles were started in 2016 in order to use the potential for improvement in the outcomes optimally between the hospitals. CARE IMPROVEMENT BASED ON VBHC PRINCIPLES VBHC focuses on optimising health outcomes that are important for patients at favourable costs. At Santeon, we have developed a model in which multi-disciplinary teams from the seven hospitals constantly compare the outcomes and costs of care in order to learn from each other.

DATA COLLECTION AND DISCUSSION Every half year, the improvement teams from the seven Santeon hospitals compare and discuss the outcomes of the care they provide based on data on the score card. These discussions address the things that are going well, and possible points for improvement. Patient characteristics that could be an explanation for variation in outcomes, costs or processes (for example, age, gender, socio-economic status and severity of the condition) are also discussed at this point. Data on the score card are not adjusted for these patient characteristics.

In each hospital, an improvement team was formed related to a specific condition. The teams consist of doctors, nurses and other professionals who play a role in the care process of this group of patients. The aim is for patients to be full members of these improvement teams as well and have a say in the choice of indicators, prioritisation of analyses and development and implementation of an improvement plan. Based on their own experience they can contribute their thoughts to how the care process can be improved. A medical specialist is the initiator of the team, supported by a project manager and a data analyst.

The data are used as a looking glass, as a starting point for discussion aimed at making improvements together. The data we compared are not results of scientific research; it does not constitute scientific evidence and cannot be used in this manner for justification. Data can be used to formulate hypotheses for possible improvements. It should not be used to draw far-reaching conclusions about the performance of participating hospitals. If differences are found, the improvement teams will discuss whether those differences are relevant and interesting enough to investigate further.

The improvement teams jointly determine a score card, with the outcome indicators, process indicators and cost indicators that are most important for the patient. These indicators form

After an initial discussion of possible causes for differences and how this is significant for patients, one indicator will be chosen to be analysed in more detail through the entire Santeon group In

follow-up meetings, the local improvement teams then choose one or two additional indicators to analyse locally. Improvement plans are then drawn up wherever possible. The analysis and design of improvement plans include the use of ‘Lean’ methodology, Santeon-wide surveys and conversations with colleagues in other Santeon hospitals to learn from each other and to adopt possible 'best practices'. The local improvement teams meet every two months in order to assess the progress of the analysis and improvement initiatives. After six months, date are again collected in the seven hospitals and the next cycle of finding differences, investigating causes and improvements starts again (see improvement cycle FIGURE 1). The Santeon hospitals cooperate openly together in these continuous improvement cycles to achieve better outcomes for patients more quickly.

FIGURE 1

SHARING OUTCOMES AND RESULTS Internally – both within and among Santeon hospitals – data from the scorecard are shared and discussed in confidence. As soon as the data are considered sufficiently reliable, Santeon makes the results of the analysis available to third parties by publishing them. This takes place after at least 3 cycles of 6-month analyses and improvements have been carried out. Santeon hospitals attach great importance to the transparency of outcomes in the care provided. This openness also offers other parties the opportunity to view care results transparently and to improve the care given to patients. EXPERTISE Since 2015, Santeon as a hospital group has been a strategic partner of the International Consortium for Health Outcomes Measurement (ICHOM). ICHOM, based in Boston (USA), works

Santeon VBHC Improvement Cycle

Starting the team and the process

Setting up the score card and improvement plan

Implementing improvements

Collecting data & looking for differences

Continuous feedback & learning

IMPROVEMENT CYCLE

Analysing differences & identifying improvements

with renowned healthcare facilities around the world to develop one set of outcome indicators for each condition. Outcome indicators show what medical care provides for a patient. These outcome indicators form the basis for the Santeon VBHC improvement cycle score cards. This will make it possible for Santeon to compare results internationally in the future. Santeon works with an international advisory board which comprises of methodological experts in the fields of VBHC, validation and data analysis. From a clinical management, public health and decision sciences perspective, they share their expertise in the field of outcome indicators and the selection

process. The advisory council discusses and critically evaluates the Santeon method, data and analyses and gives recommendations based on this evaluation. IMPROVEMENT CYCLES FOR VARIOUS CONDITIONS In the meantime, improvement teams have been launched for hip arthritis, strokes, breast cancer, prostate cancer, colorectal cancer, lung cancer, kidney damage, childbirth and rheumatoid arthritis. Improvement teams for coronary artery disease and Inflammatory Bowel Disease (IBD) are being started this year. The number of conditions will be expanded in the coming years.

From left to right: project managers: Roald van Leeuwen, Charlotte van Poorten, Samyra Keus, Annemieke van Groenestijn, Jos Kroon, Lysanne Douma and Coco Levendag 8

CHAPTER 2

Working with the Stroke improvement team

FIGURE 2

Three steps to completing a scorecard for each condition

1. DEFINITION PATIENT GROUP

2. TREATMENT OPTIONS

3. SCORECARD

• Outcomes • Costs • Process

We are sharing the outcomes of the care relating to strokes in this publication. The results1 show that the Santeon VBHC method also leads to improvements in care for this condition.

ABOUT STROKES A stroke is a common cause of death and reduced self-sufficiency. Strokes are responsible for 25% of deaths in cardiovascular diseases 2. In 2017, a total of 3,927 men and 5,570 women died of stroke in the Netherlands. In the same year, 3 21,832 men and 19,215 women were admitted to hospital in the Netherlands because of a stroke. Approximately 12% of these patients were treated in a Santeon hospital. A stroke is an umbrella term for both a cerebral infarction as well as a cerebral haemorrhage - two different conditions, often with similar symptoms. The cerebral infarction is caused by a clot that blocks one of the brain’s arteries. A cerebral haemorrhage occurs because blood from a burst blood vessel in the brain flows into the brain tissue. Significant risk factors for having a stroke include smoking, high blood pressure, atrial fibrillation, diabetes mellitus, hypercholesterolaemia, excessive alcohol consumption and obesity. Strokes result in neurological symptoms such as paralysis of an arm or leg, a crooked mouth or difficulty speaking. The symptoms that occur depend on where the stroke is present.

THE STROKE IMPROVEMENT TEAMS All stroke improvement teams include a neurologist, a nursing specialist, a project manager and a data analyst. Depending on the organisation in the various hospitals, a physiotherapist, speech therapist, occupational therapist, rehabilitation doctor, dietician, nurse, anaesthetist, geriatric specialist, team leader and manager can also be involved. The ambition is for patients to participate in the improvement team as well. For stroke patients, this sometimes turns out to be a difficult task - due to physical or mental limitations. Improvement teams looked for alternative solutions such as organising stroke focus groups. In addition, some patients are approached personally to give feedback on the stroke care. PATIENT GROUP, TREATMENT OPTIONS AND SCORECARD At the beginning of an improvement cycle, the improvement teams jointly identified the patient group, treatment options and scorecard in three steps (see FIGURE 2). 1. DEFINING A PATIENT GROUP The first step is the uniform definition of a patient

The Maasstad Hospital has been a Santeon hospital since June 2017. Since the stroke improvement cycle started in 2016, no data is available from the first cycle from the Maasstad Hospital. Martini Hospital started the improvement cycle from the second cycle, so no data from the first cycle is available from there either. For Canisius Wilhelmina Hospital, data is available only from the third cycle due to a long implementation process of the Electronic Patient Dossier (EPD). 2 www.cbs.nl 3 Source: Heart and circulatory disease in the Netherlands in 2017 from the Nederlandse Hartstichting 10

TABLE 1

Patient selection

CYCLE 1 SOURCE CVA-B / DASA INCLUSION Diagnosis: haemorrhage or infarction Incidence 1-12-2015 incl. 31-7-2016 Follow-up: 3 months Age ≥ 18 years EXCLUSION 2nd stroke Referred patients

group, so that data is collected from the same selection of patients in each hospital. For example, the decision was made to select only those patients who presented themselves directly to the particular hospital. This took the fact into account that a few of the seven hospitals fulfil a regional function - in the field of acute treatments for strokes, for example - and the data can be compared better among the seven hospitals. An overview of all the inclusion and exclusion criteria are available in TABLE 1. In the first cycle, patients were selected based on what is called the Diagnosis Treatment Combination (DTC) code. DTC codes, used for financial settlement, are easy to gather because of compulsory registration. In order to determine the reliability of this, the selection was compared

CYCLE 2 CVA-B / DASA Diagnosis: haemorrhage or infarct Incidence: 1-8-2016 incl. 31-3-2017 Follow-up: 3 months Age ≥ 18 years 2nd stroke Referred patients

CYCLE 3 CVA-B / DASA Diagnosis: haemorrhage or infarct Incidence: 1-4-2017 incl. 30-11-2017 Follow-up: 3 months Age ≥ 18 years 2nd stroke Referred patients

with the controlled – and therefore reliable – group of patients whose data has been provided by the Dutch Acute Stroke Audit (DASA), formerly known as CVA-B. Under the responsibility of the Dutch Society for Neurology, patients with a stroke are registered in this national register based on the discharge diagnosis. The difference between DTC selection and DASA turned out to be too large for a substantive analysis of care. For that reason, the data collection for cycle 1 was carried out again, this time with a selection based on the DASA register. The follow-up cycles were also carried out with patients registered in DASA. Data were collected from patients with a stroke in the period from December 2015 to December 2017 (cycles 1–3). In addition to relevant outcomes 11

and costs, patient characteristics that may affect the costs and outcomes were collected - such as age, severity of stroke, gender and socio-economic status (based on factors associated with the post code from the Central Bureau of Statistics 4). A total of 6152 patients were included based on the inclusion and exclusion criteria by the seven Santeon hospitals. Patient characteristics FIGURE 3 shows that 48% of all patients from the Santeon hospitals are aged 75 and older and 26% are under 65. The gender distribution is similar in

FIGURE 3

Distribution of age category

Santeon

Catharina

CWZ

25 31

Maasstad Martini

MST

OLVG

St. Antonius

0% < 65

65 to 74

Santeon

Catharina

CWZ

Maasstad

Martini

MST

25 25%

> 75

75%

St. Antonius 100%

24 27

OLVG

47 50%

Distribution of Socio-Economic Status (SES)

FIGURE 4

all hospitals and, in keeping with the literature, included slightly more men (54%) than women (46%). When it comes to the distribution of the socio-economic status, it can be seen that this differs per hospital. Patients in Medisch Spectrum Twente (MST) have a relatively low socio-economic status in comparison with patients from the St. Antonius Hospital (see FIGURE 4). There is a relationship between low socio-economic status and the risk of cardiovascular diseases5 but the influence of socio-economic status on outcomes after a stroke is still unknown. This will be a subject of further analysis in the future.

36 25%therapie Geen

47 50% Resectie

75% Chemotherapie

Radiotherapie ChemoradiatieSES therapie SES < average SES = average > average

100

100%

Overig

Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

Chemotherapie Overig

100

100 50 100 25 4 https://www.scp.nl/Onderzoek/Lopend_onderzoek/A_Z_alle_lopende_onderzoeken/Statusscores 5 source: pharos.nl

100

PAUL BROUWERS NEUROLOGIST PETRA VAN DER ZWAN-DOGGER PROJECT MANAGER HANNEKE DROSTE NURSING SPECIALIST MEDISCH SPECTRUM TWENTE

2. TREATMENT OPTIONS For the selected group of patients, the most common treatment options are mapped from the moment the neurologist makes the diagnosis (see FIGURE 5). First of all, a CT scan confirms if it is a cerebral infarction or a cerebral haemorrhage. In 90% of patients it was a cerebral infarction. 24% of the patients who had a cerebral infarction underwent intravenous thrombolysis and 7% of the patients underwent intra-arterial treatment. An important observation regarding the percentage is that this refers only to patients who were treated immediately in the hospital. Patients who were referred are not included in this analysis. In a later stage of the stroke treatment, 3% underwent a carotid endarterectomy. For all stroke patients, good cooperation throughout the care chain is essential. The patient is usually admitted to hospital for a brief stay and then receives paramedical care at home or geriatric rehabilitation

FIGURE 5

Diagnostics

in a nursing home, for example. The intention in the future is to include data from the entire chain in the analysis. For a practical reasons, the decision was made to start with available hospital data. Currently, possibilities are being explored to gain more insight into the outcomes of care that patients receive after they leave the hospital. Reperfusion therapy In reperfusion therapy, attempts are made to dissolve or remove the clot that causes the cerebral infarction. The purpose of this treatment is to make the blood vessel passable again in order to restore the normal blood supply. There are currently two treatment options for: 1. Intravenous thrombolysis (IVT) This treatment is effective up to 4.5 hours after the onset of the neurological symptoms. IVT involves trying to dissolve the clot that causes the cerebral infarction with a powerful blood anticoagulant via an infusion.

Overview of the stroke treatment options

Diagnosis

Brain haemorrhage (10%)

Cerebral haemorrhage (90%)

Treatment / admission

Discharge

UMC

At home

Hospital

Stroke unit

Rehabilitation centre

Intravenous thrombolysis

Physiotherapy Occupational Therapy Speech Therapy

Geriatric rehabilitation

Intra-arterial treatment

Physiotherapy Occupational Therapy Speech Therapy

Nursing home

Carotid endarterectomy

Physiotherapy Occupational Therapy Speech Therapy

Remaining

Standard step Optional / not always applied

The sooner the treatment is started, the more effective it is. The Martini Hospital and Canisius Wilhelmina Hospital have performed fewer IVT treatments than the other Santeon hospitals (see FIGURE 6). A possible explanation for this is the centralisation of the intra-arterial treatment (IAT), a treatment that can be used in a selected group of patients once IVT is no longer possible or if it was not successful. This treatment is performed only in a few hospitals in order to encourage specialisation. A hypothesis is that stroke patients are brought to an IAT centre in the vicinity of non-IAT hospitals sooner, so that this treatment can be carried out immediately if necessary. However, this is not seen at the OLVG. In addition to the centralisation of the IAT treatment, the decision to carry out IVT is possibly also affected by other factors such as the neurologist's assessment (see FIGURE 6). Several factors were examined in the literature (Ref: Levine SR et al. Stroke 2018;49:1933-1938).

2. Intra-arterial treatment (IAT) This treatment is effective for patients up to 6 hours after the onset of the neurological symptoms. Recently it has been proved that this treatment is effective and safe for a selected group of patients even up to 24 hours. With IAT, a thin catheter is inserted into a blood vessel via the groin. This catheter is moved up to the blocked artery in the brain. The clot is then removed via the catheter. IAT treatment is carried out in the St. Antonius Hospital, Medisch Spectrum Twente and Catharina Hospital (see FIGURE 7). The other four hospitals refer patients to an IAT centre nearby if needed. There is no reliable data available from this group of referred patients. However, the desire is to have reliable data regarding this group of patients in the near future. In addition, attempts are being made to gain more insight into the number of patients referred from the non-IAT centres to IAT centres (see FIGURE 7).

FIGURE 6

Percentage of patients with intravenous thrombolysis

Santeon

Catharina

23 87

CWZ

27 85

Martini MST

OLVG

15 26 30

St. Antonius 25%

50%

no intravenous thrombolysis

FIGURE 7

Maasstad

75%

100%

intravenous thrombolysis

Percentage of patients with intra-arterial thrombectomy

Santeon Catharina

MST St. Antonius 0%

92 25%

50%

no intra-arterial thrombectomy

75%

100%

intra-arterial thrombectomy

Carotid endarterectomy (CEA) Patients with a stroke and a significant carotid artery stenosis (partial closure of the carotid artery) on the same side as the stroke are eligible for a carotid endarterectomy (CEA). During the CEA, the carotid artery is opened and the calcification is then removed. This procedure is performed by the vascular surgeon. This treatment is used relatively more often in the Medisch Spectrum Twente and the Catharina Hospital (see FIGURE 8). The indications determining whether a patient is eligible for this operation are clearly defined, so this difference may be explained by patient characteristics. Another possibility is the way in which the diagnostics are carried out.

The cause of this difference will be further investigated in our hospitals. It is possible that the way care is organised locally, such as available vascular surgeons, and discussing the patients in a multidisciplinary consultation (MDC) also play a role (see FIGURE 8). 3. SCORECARD In the third step, the improvement teams determined a joint scorecard with the most significant outcome, cost and process indicators for the patient (see FIGURE 9).

FIGURE 8

The outcome indicators are based on the existing sets of outcomes from the International Consortium for Outcome Measurement (ICHOM) and Dutch Acute Stroke Audit (DASA). The main contributors to costs in the hospital are assessed for the cost indicators on the scorecard. The internal cost prices are calculated. In terms of process indicators, the moment of entry into the hospital up to the IVT or IAT was taken into account, respectively the 'door-to-needle time' and the 'door-to-groin time'.

Percentage of patients with carotid endarterectomy

Santeon

Catharina

CWZ

Maasstad

Martini

MST

6 98

OLVG

St. Antonius 0%

25%

50%

no carotid endarterectomy

FIGURE 9

PROCESS

100%

carotid endarterectomy

Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

Chemotherapie

100

Percentage response mRS 3 months after diagnosis

Infection during first admission (use of antibiotics as a proxy)

Complications arising during first admission for stroke: delirium

Complications arising after the first admission relating to stroke: unscheduled readmission in own hospital within 90 days after stroke

Overig

Stroke scorecard

OUTCOME

COSTS

75%

4.1

Unscheduled readmission because of a new stroke

4.2

Unscheduled readmission because of an infection

Length of stay per patient for 1st admission with stroke

Percentage of patients who get an x-ray

Door-to-needle time (IVT) of patients who first attended own hospital

Door-to-groin time (IAT) of patients who first attended own hospital

NELLEKE VAN WESTERING, NEUROREHABILITATION ADVISOR, CATHARINA HOSPITAL CORINA PUPPELS-DE WAARD, NURSING SPECIALIST, ST. ANTONIUS HOSPITAL MARTHÈ MOONEN, NURSING SPECIALIST, OLVG HANNEKE DROSTE, NURSING SPECIALIST, MEDISCH SPECTRUM TWENTE 17

CHAPTER 3

Results and improvements from stroke care

older for the risk of developing delirium. For example, by using Delirium Observation Screening (DOS). The aim is to recognise the symptoms of delirium early so that preventive measures can be used. Delirium poses a risk to reduced independence and premature death.

A stroke is an acute condition in which time is an important factor. Fast treatment after the incident is essential for the treatment to be more effective. In addition, our aim is for patients to stay in the hospital only for as long as is necessary to reduce the risk of complications during a hospital stay.

OUTCOMES FEW INFECTIONS DURING STAY A low percentage of infections was found during a hospital stay in all Santeon hospitals (see FIGURE 10). Extra attention is paid to the prevention of infections by, for example, optimal nursing, consulting a speech therapist early on and beginning tube feeding in a timely manner. This reduces the risk of choking and thus the risk of pneumonia. Also getting the patient moving again early on (to prevent bedsores) and not using a urinary catheter (to prevent urinary tract infections) contribute to preventing infections. At this moment, no reliable and conclusive register of complications is available in the Santeon hospitals from which it would be easy to retrieve

FIGURE 10

Percentage of patients without infection

the incidence of complications. As a result, a low percentage of infections in the register can be both the result of good care and under-reporting of complications. In order to get a clearer picture of the incidence of infections, it was investigated whether antibiotics were prescribed from day two of admission to the hospital. Taking the instability of data collection into account, it can be established that only minor differences exist between the hospitals.

Since the first data collection, it turned out that the register of complications for delirium is not conclusive. To gain more insight into the complication of delirium, the prescription of medication for the treatment of the delirium was investigated. No relevant differences were observed between the Santeon hospitals. It is possible to say that medication for treatment of delirium is prescribed sparingly during admission. Whether this is due to the fact that delirium only occurs rarely or that there are too few treatments being carried

NEARLY NO DELIRIUM Strokes mainly affect the elderly. This section of the population is more vulnerable to developing delirium. The national delirium directive recommends screening patients of 70 years and

FIGURE 11

during stay

Percentage of patients without delirium

FIGURE 12

Catharina

95 93

Catharina

85 83

Santeon

98 98

Catharina

97 98

Catharina

96 97

86 87 80

OLVG St. Antonius 20%

0% Cycle 1

40% Cycle 3

60% No data available

86 88 80%

100%

Martini

MST

CWZ 97

Maasstad

93 Martini

readmission for an infection within 90 days

CWZ

Maasstad

Martini

MST

96 96

MST

OLVG

93 95

OLVG

St. Antonius

93 96

St. Antonius

20% Geen therapie40%

0% Cycle 1

Radiotherapie Cycle 3

100

60% Resectie

80% Chemotherapie

Chemoradiatie therapie No data available

100

100%

Overig

Percentage of patients without unplanned

98 98

94 Maasstad

FIGURE 13

Santeon

CWZ

JOINT RESPONSIBILITY FOR REDUCED NIHSS The National Institutes of Health Stroke Scale (NIHSS) give a score to indicate the severity of the neurological symptoms in a stroke patient. In addition to age and type of stroke, this score is an important patient characteristic that influences the outcomes and costs of care for the patient after a stroke.

readmission for stroke within 90 days

Santeon

84 87

HARDLY ANY READMISSIONS In accordance with the ICHOM recommendation, insight was provided into the number of patients who were readmitted unscheduled within 90 days after a stroke in connection with a new stroke or an infection (see FIGURE 12 and FIGURE 13). There are hardly any readmissions of this kind in any of the Santeon hospitals. Despite the fact that no national figures are available, as far as is known, on the percentage of readmissions following a stroke, these outcomes reflect the high-quality care in the Santeon hospitals. In addition, these figures indicate that the ambition for short stay durations in the hospital does not lead to an increase in the number of readmissions.

Percentage of patients without unplanned

during stay

Santeon

Prevention is better than the cure: various measures have been taken to prevent delirium in our hospitals. For example, there is a clock on the wall to help patients with time orientation. In addition, the nursing staff take into account the retention of a day-night rhythm. The orientation of time and regularity can contribute to the prevention of delirium. In addition, the focus in the department is to remove an IV and/or urinary catheter as quickly as possible.

out will be further examined in the future. One of the joint improvement initiatives is to better register the DOS score locally. FIGURE 11 shows the percentage of patients without delirium during their stay.

99 99 98 98 98

20% Chemotherapie40%

60%

Geen therapie

0% Resectie

Radiotherapie

Cycle 1 therapie Cycle 3 Overig No data available Chemoradiatie

100

80%

99 99 100%

99 Maasstad

Martini

MST

98 98

OLVG

98 98

St. Antonius

98 98 20%Geen therapie 40%

0% Cycle 1

Radiotherapie Cycle 3

100

60% Resectie

80% 100% Chemotherapie

NoChemoradiatie data availabletherapie

100

Overig

' DURING THE ADMISSION I COULD LET GO OF EVERYTHING. THEY TOOK CARE OF ME. THERE WAS PERSONAL ATTENTION, THE NURSE CAME TO SIT NEXT TO ME TO TALK TO ME.' TREES VULTO, HANDS-ON EXPERT

St. Antonius Hospital and Medisch Spectrum Twente have a dedicated team that pays a lot of attention to the registration of the NIHSS. At these hospitals, an NIHSS score is filled out for (almost) 100% of the patients. In a number of hospitals, it appeared that the NIHSS scores were barely recorded (see FIGURE 14). This is largely explained by the fact that this score has only been one of the indicators in the rural DASA register since 2017. Various initiatives have been started to improve the number of scores recorded. IMPROVEMENT INITIATIVES Reflection At Martini Hospital, a stroke monitor is done once each month. This is a consultation with doctors, nurses and paramedics, in which they reflect the NIHSS respons rates. As a result, they motivate each other to increase the number of scores recorded. Standardisation Maasstad Hospital is involved in the implementation of NIHSS scores in their patient files so that this becomes a standard part of the working process. Until that time, they are working

FIGURE 14

on raising awareness by putting the focus more on the use of the NIHSS by the care providers involved. The most recent data from cycle 4, which was collected at the time of this publication, already shows an improvement with an increase in registration to 80%. In the third cycle this was 7%. Awareness At OLVG, the neurologist has made his colleagues, including residents, aware of the importance of NIHSS. The registration has been made easier with the EPD. Neurologists and residents now also receive a monthly NIHSS dashboard using the percentage of completed NIHSS scores. In cycle 3, the completion rate had already increased from 0 to 23%. The most recent data (cycle 4) shows that the NIHSS score registration doubled to 46%. RECORDING MRS SCORES MORE EFFECTIVELY The Modified Rankin Scale (mRS) is a tool that measures the functional status of patients after stroke. This crude measurement is the second parameter at admission along with the NIHSS which should be recorded by all hospitals in the DASA framework. The mRS is recorded in this national register three months after discharge.

NIHSS response rate

Santeon

FIGURE 15

Santeon

Catharina 50

mRS response rate 3 months after diagnosis

Catharina

CWZ

Maasstad

Martini

Martini 100 100

MST OLVG 0 St. Antonius 20% Cycle 1

OLVG

MST

40% Cycle 3

60% No data available

80%

99 98 100%

St. Antonius 20% Geen therapie40% Resectie60%

0% Cycle 1

Radiotherapie Cycle 3

100

85 80% Chemotherapie

Chemoradiatie therapie No data available

100

100%

Overig

RITU SAXENA NEUROLOGIST, MAASSTAD HOSPITAL

‘ For an individual patient, staying one day longer might not seem long. But for the group as a whole it means that many people might be rehabilitated a day later and that several people from the emergency department have to be transferred to another hospital because of lack of space. Shortening the length of stay is therefore both a cost-saving measure as well as an improvement in quality.’

Patients are usually called, often by a nursing specialist, to record this score three months after admission. In cycle 1, it appeared that in many hospitals the registration three months after discharge was missing (see FIGURE 15). The fact that registering the mRS in many hospitals is difficult was shown earlier in the analysis of the national DASA registration 6 . Discussions revealed that this particularly affected those patients who were discharged to a nursing home. To learn from each other, nursing specialists across Santeon shared the bottlenecks and successes in this area through a survey and a video meeting. Based on this, several improvement initiatives were started. These learnings came in particular from Catharina Hospital, St. Antonius Hospital and Medisch Spectrum Twente, which scored highly in cycle 1. IMPROVEMENT INITIATIVES Informing patients in advance In order to prepare patients for the nurse to obtain the mRS after 3 months, Catharina Hospital will give patients an accompanying letter that informs them about this upon discharge. The appointment for the telephone consultation is made when the patient is discharged. Inventory of causes Catharina Hospital and St. Antonius Hospital have arranged it in such a way that the nursing specialist or neurology nurse call every patient. At Medisch

Spectrum Twente, the nursing specialist obtaines the mRS directly when the patient comes to the outpatient clinic for a check-up appointment. The other patients are called. At the other hospitals, the methods for collecting these scores were more variable and primary responsibility for this was not lodged with one particular person. OLVG has now hired a medical student temporarily who calls all patients after 3 months and takes the mRS score using a structured and validated interview. As a result, the completion percentage of the mRS has increased considerably, mainly after cycle 3. Making one healthcare provider responsible for taking the mRS now appears to be the most successful method. IMPORTANCE OF PATIENT-REPORTED OUTCOME MEASURES At the moment, the focus of quality registrations is on indicators that say something about how the care process is handled within a hospital (process indicator) or about the circumstances that are needed to deliver the desired care (structure indicator). There is less emphasis on outcome indicators and, to date, the registrations of PatientReported Outcome Measures (PROMs) have been limited. This also applies to strokes. Focussing more on the outcomes of care reported by patients, sharing these outcomes with patients and healthcare professionals and using these outcomes for an improvement cycle could radically change

Data analysts from left to right: Judith Hegeman, Gerdine Pols, Heleen Hoogeveen, Yvette van der Zande- van Gestel, Jos Hendrikx, Susanne Tielemans, Marlies Zwerink, Daisy Pieterse, Doeke Bijlmakers and Hetty Prinsen

MATHÈ MOONEN ‘By comparing these improvement initiatives among STROKE NURSING the Santeon hospitals, we quickly incorporated this SPECIALISE, OLVG improvement. By means of the daily morning meeting, we

can now also set priorities for our patients more efficiently.’

REF https://dica.nl/jaarrapportage-2017/dasa

the way in which care is provided. Based on these outcomes, we can improve the care from a patient perspective and the doctor can discuss the results with the patient in the consultation room. Another advantage of using PROMs is the contribution they can make to the transfer of information in the chain. The Patient-Reported Outcomes Measurement Information System (PROMIS) is a valid and reliable measurement system that can measure the health and well-being experienced by a patient in a very efficient manner. PROMIS is generic (i.e. not disease-specific) and measures different domains. This has the advantage that PROMIS can be used in various diseases and that it is no longer necessary to register disease-specific PROMs. The value of PROMIS is currently being investigated in a variety of conditions. The use of PROMIS is also recommended by ICHOM; PROMIS-10 is part of their set of indicators for strokes. IMPROVEMENT INITIATIVE Pilot PROMIS-10 At Santeon, we are currently implementing PROMIS-10. OLVG and Medisch Spectrum Twente have now gained some initial experience with this pilot project. The next step is the commissioning of PROM digitally. PROMIS-10 is currently being implemented in the standard care process at Martini Hospital. The nursing specialist takes the PROMIS-10 during her telephone conversation with the patient (after 3 months) in addition to the mRS. The aim is to monitor the care in a structured and patient-oriented way and to use the outcomes to improve care. For stroke patients, this is an easier way to indicate their health and well-being.

COSTS The biggest cost-driver in the care of stroke patients is the length of their stay. In addition to the costs, it is important for patients not to stay in the hospital longer than is medically necessary. In connection with complications such as delirium, falls, infections and overall loss of function, it is better for the patient not to stay unnecessarily long in the hospital. It is also important from a cost perspective that beds do not stay occupied unnecessarily unnecessarily, so that they are available for new patients. This is partly due to the shortage of beds in stroke units. At the moment, patients often have to be transferred between hospitals due to a lack of capacity for admissions in the hospital where the stroke patient first arrives. QUICK AND OPTIMAL LENGTH OF STAY In cycle 1, it turned out that patients at Santeon hospitals stayed for a median duration of 5 days. Also, 5-15% of the patients in the hospitals stayed for 14 days or longer. At Medisch Spectrum Twente, the median length of a stay was 4 days. In the Santeon-wide discussion, the conclusion was reached that this difference is probably explained by the fact that supervision of the stroke unit in MST was carried out by a limited number of vascular neurologists. These neurologists expressed the importance of short admissions to the other care providers involved almost continuously. FIGURE 16 shows that Catharina Hospital has a longer median stay duration of 7 days (cycle 3). Any bottlenecks that possibly caused this have been discussed with an internal working group composed of neurologists, trainee doctors, nurses, a neuro-rehabilitation consultant, stroke chain coordinator and transfer nurses. A case study

is currently underway with the focus on internal processes around discharge management and outflow in the region. Learning from this, all Santeon hospitals have initiated improvement initiatives, which have already led to improvement in some hospitals.

from this screening are discussed with the nursing specialist the same day. They then discuss the outcomes of the screening with the patient and caregiver. In this consult, any rehabilitation process and the follow-up steps regarding discharge are discussed.

IMPROVEMENT INITIATIVES Awareness At OLVG, they are working on managing patient’s expectations. Using a leaflet, patients are informed about the importance of a shorter stay.

Daily morning meeting As a result of conversations between OLVG and St. Antonius about the method of the latter, at OLVG, a daily morning meeting is held with the paramedics. This daily morning meeting is a daily, multidisciplinary mini meeting (also called mini-MDO) at which the paramedics already distinguish who can go home and who cannot.

Daily multidisciplinary screening At St. Antonius Hospital, new patients are screened by paramedics and doctors every day. The outcomes

FIGURE 16

25%

Length of stay for a stroke

Catharina

20%

15%

10%

25%

Maasstad Cycle 1

Cycle 3

6 7 8 9 10 11 Number of days in hospital Median cycle 1

13 >=14

Median cycle 3

20%

15% 10%

MST

Cycle 1

Cycle 3

6 7 8 9 10 11 Number of days in hospital Median cycle 1

13 >=14

Median cycle 3

Martini

Cycle 1

20%

15%

10%

St. Antonius Cycle 1

Cycle 1

6 7 8 9 10 11 Number of days in hospital Median cycle 1

13 >=14

Median cycle 3

OLVG

Cycle 1

25%

20%

3 Geen 4 therapie 5 6 7 Resectie 8 9 10 Chemotherapie 11 12 13 >=14 Number of days in hospital Radiotherapie Chemoradiatie therapie Overig Cycle 3 Median cycle 1 Median cycle 3

25%

100

3 Geen 4 therapie 5 6 7 Resectie 8 9 10 Chemotherapie 11 12 13 >=14 Number of days in hospital Radiotherapie Chemoradiatie therapie Overig Cycle 3 Median cycle 1 Median 12 cycle 3

100

50 12

100

3 Geen 4 therapie 5 6 7 Resectie 8 9 10 Chemotherapie 11 12 13 >=14 Number of days in hospital Radiotherapie Chemoradiatie therapie Overig PROGRAMME LEADER Cycle 1 Cycle 3 Median cycle 1 Median 12 cycle 3

20%

15%

10%

1 Cycle 1

20%

15%

25%

10%

25%

CWZ

25%

Cycle 3

6 7 8 9 10 11 Number of days in hospital Median cycle 1

12 13 >=14

Median cycle 3

Cycle 1

100

50 12

100

3 Geen 4 therapie 5 6 7 Resectie 8 9 10 Chemotherapie 11 12 13 >=14 Number of days in hospital Radiotherapie Chemoradiatie therapie Overig Cycle 3 Median cycle 1 Median 12 cycle 3

100

50 12

With these targeted measures, OLVG succeeded in bringing the median stay duration back down to 4 days in cycle 3. REDUCED WAITING TIMES FOR DISCHARGE It is important that the transfer nurse, geriatric specialist and rehabilitation doctor are consulted as early as possible wherever necessary, so that the next steps - such as geriatric rehabilitation in a nursing home or specialist medical rehabilitation in a rehabilitation centre - can be requested as soon as possible. This eliminates the need for the patient to stay longer than necessary pending transfer to the rehabilitation or nursing home. IMPROVEMENT INITIATIVE Faster involvement of rehabilitation specialist Maasstad Hospital is in the process of setting up working arrangements to involve a rehabilitation specialist more quickly for a certain category of patients whose functioning is affected. Whether this will actually lead to shorter stays needs to be demonstrated. BETTER COORDINATION WITH THE CHAIN There can be various reasons why a stay can last longer than desired. The largest group of patients goes home after their stay. Some patients are transferred to a geriatric rehabilitation place in a nursing home or clinical rehabilitation in a rehabilitation centre. A smaller proportion of the patients are transferred to a permanent place in a nursing home due to the seriousness of the cerebral infarction or due to co-morbidity. There is a national problem with the waiting times for nursing homes. The peak discharges at 14 days confirms this. 66% of patients go home after being discharged from hospital. After an average of two to six weeks, there is an outpatient check up with a resident or nursing specialist from the hospital. Then the patients are usually transferred to their GP.

IMPROVEMENT INITIATIVES VBHC in the chain St. Antonius Hospital and OLVG discussed the possibilities with four chain partners to implement Value-Based Healthcare within the chain. All partners were very enthusiastic. In the meantime, chain indicators have been developed and data has already been requested twice from the different partners. The main focus at this moment is the quality of this data. Not all indicators can be easily extracted from systems, or are not being recorded yet. An additional problem is that the data cannot be shared at patient level for reasons of privacy. As a result, to only data at group level is shared. A temporary place A working group was formed at Martini Hospital with chain partners from the UMCG Beatrixoord Rehabilitation Centre in Haren and with chain partners from the nursing homes to work together to find a solution for the long waiting times for stroke patients who are going to the rehabilitation centre. A possible solution would be a temporary place to stay in a rehabilitation department at a nursing home, after which a patient is then transferred to the rehabilitation centre. Efficient MDO Together with one of the geriatric rehabilitation care (Geriatrische revalidatiezorg – GRZ) providers, an initiative was started at OLVG in which the geriatric specialist participates in both MDOs in the week instead of one MDO. New registration module At OLVG, a simplified module is used to register patients for a follow-up facility. As soon as a place becomes available in one of the cooperating centres (all high quality), a choice is no longer offered. The expected date for finishing medical treatment, the follow-up indication (for example geriatric rehabilitation care) and the location

that has a bed available at that time will now be determined in a single day. This allows the patient to be taken to a suitable place as soon as possible. It is also obvious that screening for a possible follow-up location will take place less in hospitals and more in the follow-up facilities themselves. At the moment, this is not possible because of partitions between the indications and the financing of the various discharge destinations. For example, the determination is made at the hospital as to whether patients should be eligible for a place in the nursing home through geriatric rehabilitation care or a place in the nursing home via the Long-term Care Act (WLZ). Organising this indication in another way could further shorten the length of stay for stroke patients who are ready to be discharged.

expect, for example regarding accommodation, aims and completion of rehabilitation.

Patient leaflets All Santeon hospitals offer patients both an admission and a discharge leaflet. This prepares the patient and families for admission, but also for a rapid discharge. At OLVG, a specific folder for discharge was made for patients being discharged to geriatric rehabilitation care. Martini Hospital is in the process of developing a chain folder to prepare patients for discharge. For example, patients are informed at an early stage about what they can

DECREASE IN X-RAYS In cycle 1, it was noted that there are significant differences in the number of patients who had chest x-rays. In the acute phase, a lung x-ray was still standard for each patient at some hospitals. In a Santeon-wide meeting with all neurologists, the effectiveness of the x-ray was evaluated and an improvement initiative was launched. Medisch Spectrum Twente shows a clear decrease in followup cycles (see FIGURE 17).

FIGURE 17

Percentage of patients without x-ray

Santeon

Catharina 69

78 76

CWZ 81 Maasstad

Martini

69 52

MST

74 76

OLVG St. Antonius 20%

0% Cycle 1

Adapted lifestyle Recommendations regarding lifestyle are made to reduce cardiovascular risk. OLVG Nursing Stroke Specialist Marthè Moonen determines the illness perception for each patient at the stroke aftercare clinic. Does the patient understand what the consequences of a stroke are and whether a change in lifestyle is necessary? Not every patient can do this independently and may end up between a rock and a hard place upon discharge. The initial period goes well, but problems with fatigue and concentration occur later on, and the old lifestyle is resumed. A follow-up check by the nursing specialist and the GP is therefore very important.

40% Cycle 3

60% No data available

86 86 85 80%

100%

Geen therapie

Resectie

Radiotherapie

Chemoradiatie therapie

100

Chemotherapie

Overig

EWOUT SCHUT NEUROLOGIST MARTINI HOSPITAL

RITU SAXENA NEUROLOGIST MAASSTAD HOSPITAL KOOS KEIZER NEUROLOGIST CATHARINA HOSPITAL PAUL BROUWERS NEUROLOGIST MEDISCH SPECTRUM TWENTE 28

PIETER HILKENS NEUROLOGIST ST. ANTONIUS HOSPITAL SANDER VAN SCHAIK NEUROLOGIST OLVG 29

PROCESS BEGINNING IVT WITHIN 30 MINUTES The sooner patients are treated, the more likely it is that the IVT treatment will have an effect. ‘Time is brain' is an oft-used term when treating strokes. Every minute that reperfusion is delayed, 1.9 million brain cells die in the case of an average cerebral infarction7. In order to start treatment as soon as possible, an optimised treatment process is crucial. The time between the arrival of a stroke patient and the start of IVT is called door-toneedle time. DICA publishes national figures every year on the basis of the DASA regarding the doorto-needle time. In 2017, the national median was 24 minutes. At the Santeon hospitals, the median decreased from 24 minutes in cycle 1 to 22 minutes in cycle 3. Within Santeon, the percentage of patients with a door-to-needle time within the standard 30 minutes has increased from 73% to 79% (see FIGURE 18). IMPROVEMENT INITIATIVES Drills OLVG is currently using drills to reduce the variation in door-to-needle time. During these drills, the admission of a patient with acute neurological symptoms is simulated. All health care providers involved are present at these drills. The drills are also a compulsory part of the training schedule for new residents. Whether the drills actually lead to less variation in the IVT process is currently being investigated.

not having a CT scanner in the emergency care department. Canisius Wilhelmina Hospital is one of the Santeon hospitals that has a CT scanner in the emergency department. As soon as the outcome is known, they can begin thrombolysis treatment directly in the CT room. Things are moving fast in the field of reperfusion therapy for patients with acute cerebral infarctions. For example, we now know that a selected group of patients will benefit from IAT up to 24 hours after the onset of the first neurological symptoms of a cerebral infarction. We recently learnt that patients who have woken up with the symptoms of a stroke (and for whom the timing is uncertain) can also benefit from IVT if they meet specific conditions. The Santeon VBHC project offers an excellent opportunity to share knowledge and experience in the field of these new scientific developments and to learn from each other. This facilitates the process of implementing these new developments. STARTING INTRA-ARTERIAL TREATMENT WITHIN 60 MINUTES For IAT treatment, the time from presentation at emergency department to puncture in the groin is also called door-to-groin time. The median of 68 minutes in cycle 3 was lower than the national median of 72 minutes. IAT treatment is performed at St. Antonius Hospital, Medisch Spectrum Twente and at Catharina Hospital. At the other hospitals, the patient is transferred immediately to a regional IAT centre for this treatment.

Faster CT scan Logistical issues can also cause delays, such as

IMPROVEMENT INITIATIVE IAT treatment After the first cycle, various actions have been set up at Catharina Hospital to improve the percentage of patients with a door-to-groin time under 60 minutes. We looked at the entire chain process around intra-arterial treatment. For example, the SEH staff received information to make them aware of the urgent importance of a low door-to-groin time. In addition, Catharina Hospital is committed to treating patients directly on the CT table. IMPROVED DETECTION OF ATRIAL FIBRILLATION The new national stroke directive stipulates that, for patients in whom the cause of the stroke is unclear, heart rhythm must be monitored for 72 hours. A major cause of a cerebral infarction is (paroxysmal) atrial fibrillation, a common cardiac arrhythmia. When patients with cerebral infarction are diagnosed with atrial fibrillation, this has important consequences for the treatment and the patient must be treated with another blood thinner (vitamin K antagonist or Direct Oral Anticoagulants). This common cardiac arrhythmia is not always present in many patients. That

FIGURE 18

is why the heart rhythm was monitored for at least 24 hours on the stroke unit in the past. The chance that atrial fibrillation is found in patients with a cerebral infarction increases as they are monitored for longer. That is the reason why the directive now recommends a monitoring period of 72 hours. Taking into account the median duration of a stay of 2 days in some of the Santeon hospitals, this means looking for innovative ways to monitor the heart rhythm outside the hospital as well. Cooperation with the cardiologist is important to achieve this. IMPROVEMENT INITIATIVE Heart rhythm monitors St. Antonius Hospital has carried out a three-month pilot with a wearable that could be fixated to the patient’s chest. This wearable is a heart rhythm meter which can monitor a patient's heart rate for 7 days before being read out by the cardiologist. Martini Hospital is working on another similar heart rhythm monitor. In the improvement team's next meeting, this topic is on the agenda to share experiences with each other, in order to find the most suitable way to identify this important

Percentage of patients with a door-

FIGURE 19

to-needle time under the standard

Percentage of patients with a door-to-GROIN time of under 60 minutes

30 minutes Santeon

Catharina

Santeon

74 76

Catharina

CWZ

48 20 47

86 Maasstad 69 Martini

PAUL BROUWERS ‘ As soon as a thrombolysis candidate is registered by a GP or NEUROLOGIST AT outpatient service, the members of the treatment team, who MEDISCH SPECTRUM are in the hospital at that time, receive a thrombolysis report, TWENTE and rush to the emergency room to be present when the

patient arrives.'

Bushnell et al; STROKE 2014:

85 86 82

MST 68

OLVG

St. Antonius

20%

40% Cycle 3

69 60% No data available

18 37

25% Cycle 1

St. Antonius

Cycle 1

MST

80%

100%

50%

75%

100%

Cycle 4*

* For this indicator, moreGeen recent data (cycle 4) became available at the time of therapie Resectie Chemotherapie publication. This concerns patients with incidence from 1-10-2017 up to and including 31-3-2018.

Radiotherapie

Chemoradiatie therapie

Overig

100

risk factor in patients after a stroke. In this way, the Santeon hospitals can look for the best instrument together and assess the material costs together with the purchasing departments. REHABILITATION DURING ADMISSION TO HOSPITAL AFTER A STROKE The stroke Knowledge Broker Network supports hospitals, rehabilitation centres and nursing homes in implementing treatment guidelines. In five years' time it has grown into a partnership of 120 knowledge brokers from 52 organisations. Catharina Hospital, St. Antonius Hospital, Martini Hospital and Canisius Wilhelmina Hospital have a 'knowledge broker' group. The group consists of at least one paramedic and one nurse per facility. That fact that one of them is a nurse brings a lot of added value, because the nursing staff have an important role in supporting patients during their stay in the hospital. This group of paramedics and nurses tries to pick up points for improvement within their own institution. Every year they have a new project that fits well with the improvement initiatives relating to strokes. IMPROVEMENT INITIATIVES Having lunch together promotes recovery Lunch groups, started at Catharina Hospital, St. Antonius Hospital and Martini Hospital, are an example of this initiative and are intended to help patients get used to the daily routine. Patients in these hospitals have lunch with each other a few days each week, where as much as possible is carried out independently. The first observation starts with walking to the lunch area, in a separate room in the ward. They then set the table and spread and cut their own bread. The Lunch Group encourages patients to move as soon as possible and, at the same time, allows care supervisors to observe their cognitive functioning and to advise whether the patient can go home safely. Several exercises are performed during this lunch session. For example, they practice opening the front door, but also remembering to turn off the stove after use.

This group is accompanied by an occupational therapist, a speech therapist, and/or nurses. It is important that nurses learn this kind of observation so that they can recognise the signs of cognitive problems during all other moments when they provide care. Practice Guide At St. Antonius Hospital, Canisius Wilhelmina Hospital and Martini Hospital, the 'knowledge broker' group also produced a practice guide in addition to the lunch group. It contains exercises to encourage movement during and after the patient’s stay in the hospital. Survey In order to learn from each other, a survey was sent out to all paramedics, in which, among other things, questions were asked about when the physiotherapist was consulted, what was discussed, what was the method of weekend treatment, which clinimetrics the therapist takes and whether an MDO is being performed. At Canisius Wilhelmina Hospital, stroke patients also receive physiotherapy during the weekend as standard. Chain training Catharina Hospital is an exception when it comes to education on rehabilitation after a stroke. A specialist will take care of translating nursing rehabilitation guidelines into practice. This person is the connecting factor in multidisciplinary collaboration, participates in the CVA Network 'Eindhoven de Kempen' and collects the DASA data. The officer provides the nursing team with insight and tools so that they can support the stroke patient 24/7. This is therefore supplementary to the work of the therapists, who are not with the patient 24/7. More than 85% of the nursing team at Catharina Hospital have been trained in this. At Canisius Wilhelmina Hospital, the knowledge brokers have developed an e-learning course on rehabilitation for stroke patients. This will be published at the end of this year.

MR W. BUSZ HANDS-ON EXPERT

' You also see other people who are in the same situation. I had trouble with my right hand and holding a knife and fork, but there was another person who could hardly get from the kitchen counter to the table.'

Lunch group: Mr. Dik and Ms. De Jonge with Gonda Levering (Physiotherapist and knowledge broker) - Martini Hospital

Part of the OLVG improvement team, from left to right: Laura Richardson, Sander van Schaik, Samyra Keus, Marthè Moonen, Doeke Bijlmakers, Sonja Corzelius, Simone Hutten

What's next? In the last two years, the Santeon hospitals have achieved something valuable. As project manager, I am really impressed by the joint improvement spirit. Active improvement teams who are working together to improve care for people with a stroke in the Santeon hospitals. Data on outcomes and costs of care has been shared in all confidence and has been accelerated to continue improving care for stroke patients within Santeon. It’s showing results. This unique way of working together also shows how important effective registration at the source is. If you do not register things correctly, you miss information that is essential when making decisions. Very nice to see how data in the improvement cycles is taking on meaning. In this area there are still steps to be taken. An important element in this is registering the discharge diagnosis at the source in our own patient file. If we do that right, we can use real-time dashboards to focus on improvement initiatives. In order to deploy the right improvement initiatives, we will have to involve patients more effectively in the improvement cycles in the future. Where this previously turned out to be feasible in the improvement teams for care in breast cancer and hip arthritis, this has partly been partially successful for strokes. We are now investigating various possibilities across Santeon to involve patients in all phases of the improvement cycles. Our starting point is that this is mandatory, we want to improve things together with our patients. This also applies to our ambition to compare patient-perceived outcomes of care in the Santeon collaboration. This can be achieved by implementing 34

Annex 1 The improvement teams

the patient reported outcome measures (PROMs) questionnaires. These are currently missing from our care and in the compulsory stroke registrations. Our goal is to use these outcomes in the consulting room and for transparency about the quality of the care we provide. We are not alone in this. Politicians, patient and professional associations and health insurers all see the importance. Together with external partners, including the Ministry of Health, Welfare and Sport, Santeon is initiating a unique 3-year programme to better inform patients about the quality of care and the benefits and risks of different treatments. With this information, patients – together with the doctor or nursing specialist – can make better decisions about which care suits them best. We will make the learning points that emerge from the programme available to all healthcare providers in the Netherlands. In addition to the ambition for PROMs and joint decision-making, we will also continue to develop the improvement cycle for stroke care. Specifically, this means that we want to search together with our chain partners for solutions for measuring in the chain and to improve flow and coordination in the coming period. This is in line with how we, as Santeon hospitals, want to improve. From the confidential exchange of working methods, experiences and successes among the Santeon improvement teams to sharing our results with the outside world. We want to do all of this for our patients and with our patients. Samyra Keus Programme Leader VBHC OLVG 35

ANNEX 1 IMPROVEMENT TEAMS INVOLVED

CANISIUS WILHELMINA HOSPITAL

MARTINI HOSPITAL (CONTINUED) Heleen Hoogeveen

Data Analyst

Anita Maalderink

Speech Therapist

Ellen van den Oever

Dietician

Mieneke Prummel

Occupational Therapist

Herma Rangelrooy

Transfer Point Nurse

Gert van Dijk

Neurologist

Sandra Timpers

Nursing Care Coordinator

Carla Damen

Senior Nurse

Karin Heijneman

Geriatric Specialist (Maartenshof)

Carla Verstappen

Neurologist

Caroline Pjpenbroek

Occupational Therapist

MEDISCH SPECTRUM TWENTE

Marjolein Looman-Bruijstens

Speech Therapist

Paul Brouwers

Neurologist

Mark van Dijsseldonk

Physiotherapist

Hanneke Droste

Nursing Specialist

Cathelijn van Koolwijk-Wijers

Trainee Rehabilitation Doctor

Petra van der Zwan-Dogger

Project Manager

Judith Hegeman

Project Manager and Data Analyst

Marlies Zwerink

Data Analyst

Charlotte van Poorten

Project Manager and Data Analyst

Bart Ament

Project Manager and Data Analyst

CATHARINA HOSPITAL

OLVG Sander van Schaik

Neurologist

Marthè Moonen

Nursing Specialist

Koos Keizer

Neurologist

Jelmer Jager

Physiotherapist

Nelleke van Westering

Neurorehabilitation Advisor

Lianka Koppelman

Dietician

Erik Driessen

Rehabilitation Doctor

Shawny Bijleven

Dietician

Bauke Thijssen

Physiotherapist

Simone Hutten

Speech Therapist

Daniëlle Boer

Speech Therapist

Laura Richardson

Occupational Therapist

Noud van Ham

Department Head

Lenie Steenmetz

Nurse

Wendy Post

Occupational Therapist

Tom Voets

Team Leader

José Messenger Bode-Meulepas

Project Manager

Aman Singh

Trainee Doctor

Susanne Tielemans

Data Analyst

Sonja Corzelius

Transfer Consultant

Peter Wesseling

Geriatric Specialist (Cordaan)

MAASSTAD HOSPITAL

Samyra Keus

Project Manager

Doeke Bijlmakers

Data Analyst

Ritu Saxena

Neurologist

Chantal van der Spoek

Nursing Consultant

Arine Verwijs Bode

Nursing Consultant

ST. ANTONIUS HOSPITAL

Chantal Hoefsloot

Physiotherapist

Pieter Hilkens

Neurologist

Stephanie Ketting

Speech Therapist

Corina Puppels

Nursing Specialist

Matthew Lane

Occupational Therapist

Patricia Passier

Rehabilitation Doctor

Frances Kok

Speech Therapist

Leonie Leus

Occupational Therapist

Mirko van der Schoot

Nurse for Department of Neurology

Marieke van Gilsdonk

Main Transfer Office

Jose Luitgaarden

Nurse for Department of Neurology

Joke Volders

Transfer Nurse

Annemieke van Groenstijn

Project Manager

Kobien Mijland

Care Manager

Gerdine Pols

Data Analyst

Ida Vulto

Department Head

Martijn Kuijper

Data Analyst

Mariëlle Hendriksen

Team Leader

Ellen Parent

Project Manager

Jos Crown

Project Manager

Robert Fetter

Data Analyst

MARTINI HOSPITAL

Mariëlle Padberg

Neurologist

SANTEON

Ewout Schut

Neurologist

Roald van Leeuwen

Programme Leader

Saskia Long

Nursing Specialist

Coco Levendag

Advisor

Gonda Levering

Physiotherapist and knowledge broker

Daisy Pieterse

Data Analyst

Francien van Nispen

Rehabilitation Doctor

Jos Hendrikx

Data Analyst

Lysanne Douma

Project Manager

Annemarie Haverhals

Programme Leader (until December 2017)

Monique Eissens

Project Manager

Hetty Prinsen

Data Manager

ANNEX 2 EXPERTS THE INTERNATIONAL ACADEMIC ADVISORY BOARD FOR INSIGHTS ON THE METHODOLOGY USED: Prof. Fred van Eenennaam, Programme Coordinator of the Decision Group Prof. Grant T. Savage, Professor of Management, Co-Director, Series Editor at George Washington University Prof. Søren M. Bentzen, Director of the Biostatistics Shared Service University of Maryland Prof. dr. Valery Lemmens, Chief of Research for EMC/IKNL

COLOPHON

Text and editing

Photography

Doeke Bijlmakers

Jan Buwalda

Paul Brouwers

Jelmer ten Hoeven

Hanneke Droste

Joep Maeijer

Jos Hendrikx

René van der Meer

Samyra Keus

Daniëlle Verweij

Roald van Leeuwen Coco Levendag Maartje Wielders Marloes de Wit

Sander van Schaik Petra van der Zwan-Dogger Marloes Zwerink Lea Dijksman

Design Telvorm graphic design

More information Santeon Herculesplein 38 3584 AA Utrecht info@santeon.nl +31 30 25 24 180 www.santeon.nl

' AS SANTEON HOSPITALS, WE BELIEVE IT IS IMPORTANT TO BE TRANSPARENT ABOUT THE OUTCOMES OF OUR CARE. BY BEING OPEN, WE CAN LEARN FROM EACH OTHER AND CONTINUOUSLY WORK ON IMPROVING CARE FOR OUR PATIENTS’ PIETER DE BEY 39

Santeon Herculesplein 38, 3584 AA Utrecht, info@santeon.nl, www.santeon.nl Canisius Wilhelmina Hospital Weg door Jonkerbos 100, 6532 SZ Nijmegen Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven Maasstad Hospital Maasstadweg 21, 3079 DZ Rotterdam Martini Hospital Van Swietenplein 1, 9728 NT Groningen Medisch Spectrum Twente Koningsplein 1, 7512 KZ Enschede OLVG Oosterpark 9, 1091 AC Amsterdam â&#x20AC;˘ Jan Tooropstraat 164, 1061 AE Amsterdam St. Antonius Hospital Soestwetering 1, 3543 AZ Utrecht â&#x20AC;˘ Koekoekslaan 1, 3425 CM Nieuwegein