Personalized Patient Care: Continuous improvement in Integrated Care Pathway for Stroke patients

In 2013, the Stroke care team from the region Roosendaal / Moerdijk, the Netherlands, was awarded for their achievements in improving patient care. They were awarded with the first prize of the Belgian-Dutch Clinical Pathway Network biannual competition for best care pathway project. One of the elements of this prize is presenting the project at the International E-P-A conference. Unfortunately, the team representatives are unable to attend ICPC2015. E-P-A still wants to share the project, a short overview of the project and lessons learned is published in this article.

The care for patients with a stroke is by definition multidisciplinary care. An integrated approach of the care process demands expertise from a neurologist, rehabilitation specialist, gerontologist, stroke nurse, physiotherapist, speech therapist, and occupational therapist. This expertise is usually present in different healthcare organizations, across healthcare settings. In 2009, the Franciscus Hospital (now Bravis Hospital), Stichting Groenhuysen, Surplus Zorg (both elderly care) en Thuiszorg West-Brabant (community care), decided to develop an integrated care pathway for stroke patients in their region.
The direct cause for the development of the care pathway were patient needs. From patient experience reviews, it was clear that patients perceived the care process as complex and unstructured, they were confronted with numerous different professionals and experienced discontinuity in care when they were transferred.

“I saw so many nurses, and everybody gave information about my illness. At one moment I couldn’t see the wood for the trees”

40 Representatives from the involved organizations met to decide on the goals of their quality improvement initiative. They set three goals:

Personal coordination for stroke patients – in each organization, the patient would have one care coordinator, responsible for communication with the patient and his family.
Continuity of care – continuity in person and continuity across organizations.
Uniform and clear care process for patient and relatives.

The care pathway is set up for continuous improvement. An integrated care pathway across all involved organizations was deemed too complex to design in one go. The idea was to start with the development, get buy-in from stakeholders, and use that to improve the care pathway.
Working with 40 people in one project is virtually impossible. That is why the project team was divided in sub teams in three tiers: Coordination team, providing overview and combining the results of the Stroke care pathway teams, in each organization responsible for the development of the care pathway, and Functional care teams, the teams of professionals caring for the stroke patients.
For the project approach, the 7-phase-method was used.


The following results show why the jury of the competition awarded the stroke team.

table stroke

All patients in the region receive thrombolysis within 1 hour, compared to 85% in the national stroke benchmark.

More information: please contact mrs Elly van Meer – Roelen, Stroke care coordinator