Mechanisms of Improvement
The Method Integration for Stroke Transition (MIST) project: Developing an integrated health care quality improvement and research method to improve processes and outcomes - examining transitions from hospital to home for stroke patients
What we know
Quality improvement methods and health services research are important methods through which better health and social care outcomes can be delivered – however each has its limitations.
Whilst quality improvement initiatives in Scotland have made some notable achievements, the methods used are not always effective in explaining successful and less successful outcomes, making spread and sustainability difficult, and replication unlikely.
In contrast health services research and evaluation methods are diverse, and seek to develop knowledge, explanations and outcomes that are robust and replicable.
However, standards for research can be viewed within services as too rigorous; taking too long to generate useful knowledge for health and social care services under pressure to respond to rapidly changing demands and resources. Seeking ways to better integrate quality improvement methods and health services research to address complex healthcare problems in timely but rigorous ways may address limitations in both approaches.
The Method Integration for Stroke Transition (MIST) project aimed to explore how we can integrate rapid and locally responsive quality improvement methods with rigorous and theoretically informed health services research methods. The aim is to increase the impact of quality improvement initiatives, by maximising potential success, spread and sustainability. We will use transitions from hospital to home as an exemplar topic with which to examine the development of novel integrated quality improvement and health services research methods.
Examining transitions from hospital to home for stroke patients, the objectives were:
- To identify principles, services and processes required to ensure good healthcare transitions for older people and people with disabilities including stroke
- To identify current problems and processes involved in healthcare transitions after stroke using participatory methods with key stakeholders
- Bring key stakeholders, experts in research methods and HQI methods together to co-create solutions and to explore how HQI and HSR methods can be integrated to effectively address problems.
- Develop innovative integrated HQI methods that can be tested in practice and in future projects.
What this research explored
There were three distinct stages to this research, that enhanced knowledge around this key area of care and demonstrated the benefits of including stroke survivors and carers to enhance service provides understanding. This enhanced knowledge, was then used as a mechanism to explore the improvement and research approaches to address the co-produced priorities and understand the opportunities to integrate and enhance these distinctive methodologies.
Rapid review of stroke transition literature
A rapid review of the stroke transition literature to find literature that provided evidence on how the care transition for stroke survivors between in-patients and community settings could be improved, was conducted.
Stakeholder event to explore transition
This event involved stroke survivors, carers and health professionals to explore the challenges they face in the transition from hospital to home. The aim of the day was to develop a better understanding the problems in stroke transition from both a service user and health provider perspective and enabled the co-production and identification of three key areas for improvement.
Expert Consultation event
A second stakeholder event that included health services researchers, quality improvement experts, stroke survivors, carers, stroke-focussed health professionals and third sector organisations to consider methodological strategies to address stroke transition problems. The purpose of the Consultation was to integrate research and quality improvement methods to explore how these knowledge-generating, problem-solving methods can be most appropriately used to address complex problems such as transitions in stroke care.
What this study adds
Data synthesis from the rapid review highlighted the issues of poor inter-organisational coordination and collaboration and the prioritisation of health service needs over stroke survivor and carer needs. This resulted in a range of unmet physical, psychological, social and information needs leaving stroke survivors and carers feeling stranded and alone navigating the health system post-stroke.
These findings were also reflected in the outputs from the Stakeholder engagement event, where three very clear areas of improvement were identified:
- Abandonment and Finding Your Own Way
- Accessing Community Services, Support and Peer Support
- Support and Planning for Transition
While health services research (HSR) and quality improvement (QI) methods are typically viewed as (and completed in) distinct areas, the Expert Consultation participants found that there was stronger alignment between QI and HSR than expected. Indeed, rather than being at odds with one another, these differing skills sets provide rich opportunities for strengthening one another by dovetailing expertise.
Many QI and HSR experts expressed a measure of surprise at the potentially rich methodological offerings of the other and despite the original intent of the project to develop a specific, hybrid method; the Expert Consultation participants reflected that a combined approach did not require a new creation but rather a new approach to collaboration.
Benefits and impact
The MIST project contributed to SISCC’s goals of collaborating for improvement by bringing together an array of previously disconnected stakeholders to learn from and about one another, drawing on the strengths each stakeholder holds, to bring about new understanding that can lead to effective, efficient and sustainable improvements.
The study found that QI and HSR methods appeared to be readily integrated to develop a mixed methodology and pointed to the essential need to value and understand one another in order to enable proactive collaboration. This work offers the opportunity to develop an HSR-QI collaborative approach, combining complementary HSR and QI expertise and experiences together that would enhance improvements to processes and outcomes around stroke transition and other areas of care.
This project was led by Dr Jacqui Morris, Reader in Rehabilitation and Dr Tricia Tooman, Research Fellow, University of Dundee, in conjunction with colleagues from the School of Health Sciences at Dundee, Healthcare Improvement Scotland, NHS Grampian, NHS Tayside, Queen Margaret University and University of Stirling.
For more information please contact SISCC (firstname.lastname@example.org)