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NINDS: Stroke Proceedings: Royer

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Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

Overview: Health Care Systems
A Must for Integrated Disease Management: A Focus on Acute Stroke Care

Thomas C. Royer, M.D. (Session Chair)
Henry Ford Medical Group, Detroit, Michigan

Introduction

We are in the midst of the most significant decade of change for health care delivery in America. Government, business, and, most importantly, our patients and their families are speaking out to tell us that the care we provide is often not acceptable and many times not affordable. These voices are demanding a transformation in the delivery of health care, with managed care accepted as a style of practice rather than a payment mechanism.

This transformation in the health care system provides the infrastructure for the rapid identification and treatment of acute stroke since it emphasizes delivering care in a continuum rather than in fragmented episodes, and it is focused on primary intervention rather than inpatient procedures only. To make this transformation successful, it will be helpful for health care providers to see themselves as part of a three-dimensional delivery model.

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The Three Dimensions of An Integrated Health Care Delivery System

Envisioning a three-dimensional model can help to conceptualize how the different components of a health care system must be integrated and set in motion to achieve the highest quality of care at the lowest cost for any disease process. These components can be connected formally, as in a largely owned urban health care system, or informally by strategically aligning all the delivery parts serving one geographic population.

The first dimension is "growing" all the parts necessary to provide the continuum of care for the disease process. The second dimension is connecting all the parts to form a seamless delivery system. The goal of this step is to ensure that patients not only have access to all components of the system, but can also receive maximum benefit at each treatment location. The third dimension requires the creation of clinical process improvements for disease management horizontally through all the treatment locations to assure that the outcome will create the greatest value for the patient--the highest quality of care at the most affordable cost.

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The Treatment of Stroke: Connection to the Three Dimensions

Each of the other four sections in this monograph--Prehospital Emergency Medical Care Systems, Emergency Department, Acute Hospital Care, and Public Education--represents an important part of the first dimension of acute stroke identification and treatment. The second dimension represents the effective and efficient integration of these services. In a given geographic area, a large health system must provide, or smaller components must come together to provide, all of the services needed by a patient having an acute stroke. Through planning and cooperation, this second dimension will allow for the regionalization of locally delivered and centralized services. The third dimension strategically aligns these acute stroke identification and treatment services so that the patient can move efficiently and rapidly from one point to the other. All care providers operating in these delivery systems must develop and implement the best practices, established guidelines, and expectations for each service required in the acute stroke continuum. Initiatives for improving acute stroke clinical processes--the third dimension--should focus on reducing unintended variations and support ongoing improvements and innovations. These initiatives will help us improve our daily work.

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Questions We Must Ask

Regardless of the part of the health care delivery system we represent, all of us seek the knowledge needed to improve acute stroke identification and treatment in our communities. Our tasks can perhaps be summarized best in the following questions:

1. What delivery system are we a part of formally or informally?

2. Are we prepared to strategically align the necessary service parts to rapidly identify and treat patients with acute stroke?

3. Are we willing to adopt the guidelines necessary to create a clinical process across all the service parts to reduce unintended variations and increase ongoing improvements?

4. Are we willing to identify and remove barriers to foster a more rapid cycle time for the processes described in this monograph?

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The Ultimate Purpose of the Effort

We are all connected to health care because we want the best outcomes for our patients and their loved ones. As we learn about new treatment processes, we must not only implement them, but we also must measure our performance across the system using standardized techniques. These measurements should include clinical quality, functional status, patient satisfaction, and cost. Establishing a system fosters internal and external benchmarking of the best practices to promote ongoing improvement and innovation. The rapid identification and treatment of acute stroke demands a focus on this purpose.

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Summary

The best practices to rapidly identify and treat acute stroke victims are outlined in the reports presented in this monograph. To implement these practices, all parts of the delivery system must come together in a coordinated and three-dimensionally integrated fashion. The often disjointed collection of tangentially related service points of the past cannot be tolerated in the future. Working together as part of a larger health care delivery system, we can deliver the most efficient and effective acute stroke care.

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Last Edited: January 13, 2000

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892

Last updated June 19, 2008