Process Evaluation of an Effective Multifaceted Quality Improvement Intervention to Improve Acute Stroke Care: Unpacking the Success Factors and Challenges

Background: The Shared Team Efforts Leading to Adherence Results (STELAR) program is a multifaceted quality improvement intervention directed at hospital clinicians to improve stroke care. In a stepped-wedge cluster trial (N=9 hospitals, Australia), STELAR achieved a 17% improvement in adherence to prioritized clinical indicators (composite outcome). We report the critical success factors and challenges that influenced change in care delivery. Methods: STELAR included two externally facilitated workshops; (i) feedback of national registry data to identify practice gaps and prioritize indicators; (ii) barrier assessment and action plan development (2017-2018). Hospitals appointed a site coordinator, and identified local change champions. Two months of remote-support followed to implement action plans. The process evaluation included workshop observations (N=18), document review, satisfaction surveys (N=51), and semi-structured interviews (external facilitator, N=9 clinician site coordinators). Qualitative data were mapped to an implementation framework before inductive thematic analysis. Quantitative data were analysed descriptively, with all data triangulated. Results: Critical success factors included delivery by knowledge translation experts, external facilitation support/nudging to maintain staff engagement at hospitals, and the use of evidence to self-select prioritized indicators. Involving multidisciplinary staff in action planning and supporting local change champions to lead the implementation fostered capacity building. Reported challenges related to insufficient time when focusing on several prioritized indicators simultaneously within a limited timeframe and having to address strategies that involved working with different clinicians or hospital departments. Staff workload and availability and lack of medical buy-in and management support during the process were wider organizational challenges reported. Conclusion: Despite the identified challenges imposed by the limited implementation period, STELAR’s multifaceted attributes underpinned the overall strong positive change in quality of stroke care. Implications for wider adoption include involvement of knowledge translation experts with ongoing support for capacity building, and allowing greater time to work through implementation strategies.