SEEN on a map, these cities form a perfect triangle – Coimbra in the west, Tondela in the north, and Castelo Branco in the east. Roughly inside the triangle lies Portugal’s Centro region, a place of rugged beauty, rich history – and lately also promise, for it is here that the Portuguese stroke community’s quality monitoring programme is gaining the traction it needs to succeed.
The revised programme requires hospitals to submit stroke patient data to RES-Q or SITS-QR for any complete month per semester. When the programme was first launched in 2021, March and November were designated data collection months, but it is expected that a more flexible approach will help overcome barriers to consistent data collection.
In the Centro region this flexibility was treated as an opportunity to submit data sooner rather than later. In fact, all stroke-treating hospitals in the region submitted patient data for January 2023, acting decisively and in unison to improve stroke care in the region, and setting a benchmark for hospitals in other parts of the country.
The inspiration for this outstanding achievement can be found on the same map where a little imagination allows you to see two bright spots – one in the west, where Dr Gustavo Santo is a neurologist at Coimbra Hospital and University Centre (CHUC) and the Centro regional stroke code coordinator, and another in the north, where Dr Ana Gomes is the stroke unit coordinator at Tondela-Viseu Hospital Centre as well as Portugal’s RES-Q coordinator.
With 19 ESO Angels Awards earned since 2018, including 10 diamond awards, Tondela-Viseu Hospital is a shining example of the impact of quality monitoring on stroke care. Dr Gomes spells it out: “Quality monitoring allows us to evaluate our indicators, recognise our ‘weak points’ and correct our performance. And when we reach certain quality targets, it motivates the team.”
Dr Gomes is upbeat about the potential impact of the Melhora Quem Sabe initiative on stroke care in Portugal. “Concrete data will bring to light disparities between hospitals and the problems that impact stroke care quality, but this impact is very dependent on participation. Overwhelming workloads and insufficient management support for quality monitoring discourage hospitals from registering patients. At our hospital, too, the heavy workload and large volume of patients have at times made it impossible for me to register patients consistently, something we have overcome by making teammates co-responsible for data collection.”
Dr Gomes believes that being able to choose a month for data collection will help bring more stroke units on board.
A 50-minute drive from Tondela, in Coimbra, Dr Gustavo Santo is leaving nothing to chance. Coimbra Hospital and University Centre is the region’s referral hospital for thrombectomy and telemedicine hub, and Dr Santo has taken an active role in rallying Centro hospitals’ participation in the Melhora Quem Sabe initiative.
“He contacted every single hospital in the region and encouraged them to submit their data,” says Inês Carvalho, Angels consultant for Portugal. Dr Santo’s presumably vigorous style of encouragement sparked the ambition of all the hospitals in the network, preparing the ground for data-driven improvement in the region.
Dr Santo plays down his own contribution, saying he merely participated with many other health care professionals in getting hospitals in the regional network to share their data for January 2023. But Inês sets the record straight: “It was possible because he insisted.”
Dr Santos is, like Dr Gomes, an advocate for quality monitoring, believing it should enjoy a “central role in the design of organisations”.
“It lets you rigorously examine the points of failure in the chain of care, and implement corrective measures. We cannot correct what is unknown.”
Dr Santo says hospitals in the network have generally been responsive despite the pressures of human resource shortages and high staff turnover during a challenging period in the national health service.
“The merits of quality monitoring are self-evident,” he says. “The hardest part is to combine the will to measure, record and evaluate with the means to do it.”
In Castelo Branco, at the third point in the triangle, Dr Eugénia André and Dr Raquel David have found both the will and the means. Hospital Castelo Branco is not yet an award-winning stroke centre, but its newly minted commitment to quality monitoring and team’s enthusiasm for partnering with Angels sets it apart as a future bright spot in stroke care.
Dr David lists the reasons that convinced them to participate in the data collection initiative: “Awareness of how treatment delays impact the patient’s survival and quality of life; the desire to know more about our current performance; the opportunity to learn from our peers by sharing information, and the support of Angels.”
Here, as elsewhere, it’s teamwork that overcomes the challenges of staff shortages and consequent lack of time. “Our strategy has been to distribute tasks and have a well-organised system for data collection so team members can step into each other’s shoes when necessary,” she says. Nurses compile the information in a database from which it is later exported to the RES-Q platform.
Involving nurses in data collection is very important, Dr Santo says. “They play a decisive care role that impacts multiple quality indicators.”
For hospitals in other regions that have not yet submitted their data for the first semester of 2023, Dr Gomes has the following advice: “Gather your team to make them aware of the project, choose one of the registries (RES-Q or SITS-QR), select a month, and participate by collecting data for all stroke patients.”
Dr Santo’s advice is even more succint: “Só melhora quem sabe!”
You can only get better if you know.
