Lean stroke project speeds U-M stroke care

Neeraj Chaudhary, MBBS, assistant professor, radiology; Joseph Gemmete, M.D., associate professor, radiology; and B. Gregory Thompson, Jr. M.D., professor, neurological surgery

The University of Michigan Stroke Program is taking a tip from the automotive industry by using "Lean" Thinking - a quality improvement philosophy that removes waste from processes and attacks problems at its roots. Since the creation of the Lean Stroke Project Team one year ago, U-M has finely honed its stroke arrival process to benefit referring physicians, U-M faculty and health care staff and, most importantly, stroke patients.

"Stroke is a complex disease process requiring collaboration from multiple surgical/medical specialties," says Aditya S. Pandey, M.D., assistant professor of neurosurgery.

Neurology, Neurosurgery, Neuroradiology, Cardiology, ICU, Anesthesia, Rehabilitation, Physical Therapy - every component of the hospital that works with stroke patients, and even outside entities such as emergency medical services - were brought into the process.

The Lean Project Stroke Team meets regularly, sharing feedback and reviewing statistics that are recorded in real-time to monitor door-to-needle times. The team identified several key issues including the need for:

• A standard process of accepting emergency department-to-emergency department transfers
• Better communication and standard processes for patients to access our system.

The Lean Stroke Project Team's goals were:

• To create a standard system approach for all stroke patients
• To implement American Stroke Association Best Practices and
• To create a monitoring system with prompt data feedback.

Results of the many improvements of the team so far:

• Developed new emergency department stroke screening and activation processes, and added the Anesthesia service to the team
• Implemented a Neuro-Interventional Radiology single activation system
• Updated emergency department-toemergency department transfers to facilitate the acceptance of patients at U-M
• Began pre-hospital activation by working with ambulance groups to have the stroke team meet patients in bay
• Updated the CT requisition for stroke and angio orders so that CT scans for these patients are a high priority
• Developed real-time stroke arrival monitoring for continuous improvement to ensure that the door-to-needle timeframe is under 60 minutes and/or that patients are expedited to Interventional Radiology as necessary.

"Our infrastructure for stroke care has become more efficient in allowing early diagnosis and treatment while being able to offer a comprehensive spectrum of medical, neurointerventional and neurosurgical treatment alternatives that simply are not available in most stroke centers," Dr. Pandey says.

The team used Lean tools and processes to revamp the stroke arrival process. For example, team members created a map of the entire arrival process, beginning with the onset of symptoms all the way to the patient being assigned to the appropriate bed.

"We're treating stroke more like trauma," says William J. Meurer, M.D., assistant professor of emergency medicine and neurology. "We're identifying the patients quickly and treating them quickly."

"Quality of care is most important to us," says Lewis B. Morgenstern, M.D., director of the Stroke Program and professor of neurology. "We work extremely close together to provide the highest quality care for our patients."

The University of Michigan is accredited as a Primary Stroke Center by the Joint Commission and participates in the American Stroke Association Get With the Guidelines Quality Initiative. And UMHS is one of only two stroke programs in the state of Michigan to receive the American Heart Association's Gold Plus designation for quality of care.

In 2013, the Joint Commission will add stroke core measures to its guidelines for hospitals. And, as lean coach Sheri Moore says, "The University of Michigan Health System will be more than ready."

Emergency department-to-emergency department transfers:
call 734-936-6666.

For clinic appointments to the U-M Stroke Program:
call M-LINE at 800-962-3555.