Facilitators and barriers to applying a national quality registry for quality improvement in stroke care

Abstract

BackgroundNational quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden.MethodsA strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR’s criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis.ResultsAn NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data.ConclusionWhile quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

“…In line with this, a previous study has suggested that the presence of a purposeful and active management system supports planning, performing, and follow-up and thus contributes to continuous quality improvements. 43 Thus, future studies should attend to and explore how the leadership model fits with present management systems, or identify and attend to needs for adjustments. The insufficient routines for evaluation and feedback to staff members about their clinical performance in some of the participating units could have contributed to the discrepancy in views between managers and staff members regarding guideline recommendations and actual clinical practice.…”

The Danish Cardiac Rehabilitation Database

“…The growing literature indicates that clinical quality registries can provide vital information that can be used to facilitate improvements in practice16 with positive effects primarily on the processes of care, whereas measures on outcome of care are less often positively affected 16. Findings, however, are heterogeneous, indicating that neither a registry itself nor the reporting of data initiates change as quality improvement requires comprehensive approaches,17 including successful implementation of the registry and continuous data quality assurance, as well as transparency and timely feedback 18. Based on experiences from the field of stroke care, embracing a comprehensive quality assurance approach, including a culture with focus on quality, thorough data entry, and availability of feedback as well as willingness to act on feedback, is critical in order to achieve improved quality of care 18.…”

Factors facilitating a national quality registry to aid clinical quality improvement: findings of a national survey

“…Our previous study showed that staff members engaged in Riksstroke at the stroke unit level are aware of the need to identify unique selling points to involve their colleagues. 13 However, more collaborative efforts and an understanding of quality improvement are necessary if the data are to help improve stroke care and not just provide feedback. Managers are often considered key to support clinical quality improvement, 13 14 31 which our findings also support.…”

“…We identified sets of dependent and independent variables (indexes) by processing theoretical knowledge and clinical experience, including our previous qualitative studies, 13 …”

“…12 Previously, using Riksstroke as a case in a series of qualitative studies, we found barriers and facilitators for quality improvement within the registry itself and in the interplay between inner and outer stroke care contexts. [13][14][15] Beyond particular stroke process projects, the use of Riksstroke was ambiguous and highly dependent on devoted professionals in stroke units and among stakeholders at the politicoadministrative level. While these studies provided a profound understanding, including a sample of stroke care in Sweden, a more comprehensive understanding of how an NQR like Riksstroke promotes quality improvement is needed.…”