| 4. In which ways is the initiative creative and innovative?
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Prasat Neurological Institute collaborated with the Thai Stroke Society, the Neurological Society of Thailand, and the Royal College of Physicians of Thailand established National Clinical Practice Guidelines for thrombolytic treatment of stroke and how to setup stroke unit, and has distributed to related healthcare professional around the country several years ago. However, just a small number of hospitals in Thailand can provide the service in real practice. Therefore, Stroke Service Network initiative which is an academic network has been established as a tool for engaging stakeholder and Memorandum of Understanding has been signed to develop collaboration between the Prasat Neurological Institute and each hospital. Apart from formal training, a processes of knowledge management have been used to improve the quality of care in each hospital. In addition, quality indicators (e.g. in-hospital dead rate, rate of medical complication, etc.) have been collected and compared among hospitals in the network (ie. benchmarking), the hospitals that have best practices is asked to share experiences among hospitals in the network.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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Prasat Neurological Institute implemented the Stroke Service Network initiative, which is academic network included 112 hospitals around the country. The implementation of this initiative has resulted in improving the treatment of stroke patients throughout the country, that is, numbers of hospitals capable of providing fast track service for stroke patients and stroke unit have been increased, particularly in rural region. Because around 168,000 new cases of stroke occur each year in rural region. Therefore, these have resulted in patients of around 168,000 per year in rural region being able to access to fast track service and stroke unit, which lead to reduce the occurrence rate of complications (e.g. chest infection, urinary tract infection, etc.), length of stay in hospital thereby reducing the expenses incurred to the patients themselves, their families and the government. Most importantly, it will go to reduce the in-hospital dead rate and disability of survivors, thereby increasing quality of life of the patients themselves and their families.
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| 6. How was the strategy implemented and what resources were mobilized?
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To reduce in-hospital stroke dead rate in Thailand, it need to establish standard stroke treatment such as stroke fast track for thrombolytic treatment and stroke unit in hospital around the country, particularly in rural area. The implementation steps for establishment of standard stroke treatment services around the country consist of four steps as following 1) network establishment 2) knowledge transference 3) site visiting and 4) service quality certification.
Network establishment was done by inviting hospitals in all region of the country to join the network. For sustainable development, Memorandum of Understanding to develop collaboration was signed between Prasat Neurological Institute and each hospital. A set of 29 quality service indicators were developed and recorded in computerized database system for measurement and monitoring the level of development of each hospital and also using as a tool for benchmarking among hospitals in the network.
Knowledge transference was performed. Apart from several formal short training courses provided by Prasat Neurological Institute (e.g. 5 days of basic stroke training course for nurse, 5 days of advance stroke training course for nurse, stroke service manager course, pitfalls stroke management for physician, etc.), processes of knowledge management were used to facilitate the development such as creating, sharing, using and managing the knowledge and information have been applied.
For seeing the real situation in each hospital, site visiting with walking around each hospital in the network by doctor and multidisciplinary team from PNI were performed. The main purposes of each site visiting were to follow up the level of development, to see the real current situation, to assist performing gap analysis for development, and to give an advice for further development according to context of each hospital.
Each hospital was encouraged to do self evaluation periodically by using self assessment form. If the hospital passes those criteria based on self assessment, team from Prasat Neurological Institute will visit those hospital for formal assessment and verification of service quality. Hospitals which fulfilled the standard criteria of the good service will receive service quality certification, that is, stroke unit certification which is valid for 3 years. For sustainable and continuous development, 29 collected indicators have been regularly used for benchmarking among hospitals in the network.
The resources for this initiative mainly consist of personnel of Prasat Neurological Institute, namely, the management team, medical doctors specialized in neurology (neurologist), medical doctors specialized in radiology, nurses working in emergency department, nurses working in stroke unit, pharmacists, as well as personnel for administrative work. Budget supporting the initiative come from 3 sources, namely, Prasat Neurological Institute, Department of Medical Services, and the Ministry of Public Health. A greater part of the budget has been spent on conducting training for medical personnel in the network, preparation of documents for training, cost of building the on-line database through the internet, cost of traveling and accommodations in case of conducting site visit to hospitals within the network. At the beginning, the budget was made available by Prasat Neurological Institute only. Later, due to the increase in the number of members of the network, additional budget was supported by Department of Medical Services and the Ministry of Public Health. Hospitals within the network do not pay for the cost of trainings nor the expenses related to visitations.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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The initiative was designed by management team and multidisciplinary team related to stroke patient care of Prasat Neurological Institute and of Department of Medical Services after situation of stroke system of care in Thailand and how to improve the quality of care, in term of the whole country, were analyzed. Based on context of developing country as Thailand, the appropriate system of stroke care and appropriate way to implement were determined.
The team which contributed to implementation included expert staffs from Prasat Neurological Institute and staffs of the 112 hospitals in the network. Among these 112 hospitals, most hospitals (84.8%) were hospitals affiliated with Ministry of Public Health. Other hospitals included private hospitals (9.8%), medical schools (3.6%), hospitals affiliated with Bangkok Metropolitan (0.9%) and hospitals affiliated with Ministry of Defence (0.9%).
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| 8. What were the most successful outputs and why was the initiative effective?
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The Stroke Service Network initiative has been in operation since 2009 and continuing up to the present. The main outputs of the initiative were 1) trained medical personnel with good knowledge of stroke care (up to present, approximately 3,876 persons) 2) best practice of stroke care in each step of care according to context of each hospital 3) computerized database of indicators for monitoring service quality and for benchmarking 4) increased number of hospitals which had standard of care for stroke, that is, stroke fast track service for thrombolytic drug treatment and stroke unit and 5) learning network for continuous and sustainable improvement.
Most of trained medical personnel were nurse. However we also trained medical doctors and other paramedic who involved in the system of stroke care.
The context of each hospital are often different from each other. Hospitals that had good performance outcome, evaluated by using quality indicator (e.g. lower rate of complication, lower rate of death, etc.), were asked to share the experience with other hospital by story telling about how to do and then was recorded as best practice for further study by other hospital.
Computerized database has been established. Quality indicators (29 indicators) of service care were regularly recorded in the database by each hospital via internet network. We regularly used these data for measurement level of development and also as a tool for knowledge management such as identification of the best practice for sharing, identification of knowledge need, etc.
Around the country, the number of hospitals affiliated with Ministry of Public Health, i.e. regional hospitals (having more than 500 beds) and general hospitals (having around 300 to 500 beds), which can provide stroke fast track service for giving thrombolytic drug has increased from 28.2% in 2009 to 98.8% in 2016. Stroke unit service has also significantly increased in these hospitals from 12.9% in 2009 to 61.7% in 2016. Although not all (100%) of these hospitals provided stroke fast track service and/or stroke unit service, these services have covered all regions of the country which lead to decrease in-hospital dead rate of stroke patients in Thailand from 15.1% in 2009 to 8.3% in 2016.
For being a learning network, knowledge management processes (e.g. essential knowledge identification, knowledge sharing, mentoring system, etc) have been applied regularly in the network.
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| 9. What were the main obstacles encountered and how were they overcome?
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Although thrombolytic treatment and stroke unit service are effective treatment for stroke, these services are quite novel, particularly for developing country. In addition, to establish these services, it need good cooperation from each member of multidisciplinary team. Therefore, the main obstacles in implementing the initiative were that management team of many hospitals did not recognized that these services is essential and certain parts of the personnel in Prasat Neurological Institute and majority of personnel in other hospital in the country did not have knowledge of these kind of services. Some personnel believed that these treatments were not effective, too complicated and too expensive to be established.
To overcome these obstacles, we invited management team including director of regional and general hospitals as well as other hospital in network around the country to join the meeting and gave information about huge burden of stroke in Thailand and benefit of standard treatment service compared with traditional treatment service and asked them to join the network for standard services development together. Apart from management team, we also gave information and benefit of these services to working personnel in each hospital, particularly in term of reducing death and disabilities rate of patients. In addition, we showed the effectiveness, that is, patient had been dramatically improved after received thrombolytic treatment by real case demonstration.
During implementation, director or management team of some hospitals were changed which lead to discontinuation of development of the services. To ensure the continuation of development, we asked director of each hospital to sign Memorandum of Understanding with Prasat Neurological Institute.
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