Russell, L.
(2024)
The Sentinel Stroke National Audit Programme: An improvement tool for community stroke care?
PhD thesis, University of Nottingham.
Abstract
Background
The Sentinel Stroke National Audit Programme (SSNAP) is an established quality improvement tool for hospital-based stroke care. It is the only national stroke audit that collects data detailing stroke care beyond hospital discharge. However, its role in driving quality improvement in the community setting was unexplored.
Aim
To understand the role of national clinical audit in driving quality improvement in community stroke care.
Methods
This thesis consists of four phases of study, each informing the next. Phases used distinct research methods as part of the overall realist evaluation.
i. A scoping review of the literature exploring the contextual features that influence the contribution of externally initiated, multidisciplinary clinical audits to quality improvement.
ii. A mixed-methods online survey investigating stakeholder experiences of SSNAP in the community setting.
iii. Realist interviews exploring what influences the ability of SSNAP to contribute to quality improvement in the community setting.
iv. National clinical audit data was used to explore the use, and interpretation of a patient reported outcome measure (EQ5D-5L) as part of quality improvement in community stroke care.
Results
The scoping review identified important features pertinent to audits that are multidisciplinary and externally initiated. The findings suggest individual engagement to be influenced not only by a perception of the audit and its purpose, but also by perceptions regarding credibility and organisational culture. Findings were used to develop an online mixed methods survey.
The survey captured the perspectives of a broad range of stakeholders in different roles from across England, including administrative, clinical, management and commissioning (n=206). Participants reported being engaged in the audit and using feedback to inform a variety of quality improvements. Teams were described as committing significant resources to audit participation, despite facing a number of barriers. Challenges to audit participation were highlighted such as the administrative support available, the inflexibility of the online audit platform and the ability of the audit to reflect the services delivered in this setting. Findings were used as a framework for subsequent realist interviews.
Interviews were undertaken with a broad variety of stakeholders in different roles from across England (n=20). The findings generated greater understanding of the contextual features in community stroke care and the mechanisms by which these influence the ability of the audit to drive quality improvement in this setting. Four theories have been proposed that seek to explain the mechanisms by which SSNAP contributes to quality improvement in community stroke rehabilitation.
Firstly, organisational support such as leadership interest, the fostering of champions and dedicated administrative support legitimizes audit activity. This provides opportunities for skill sharing which motivates team engagement with the audit. Secondly, an accessible audit feedback report enables leaders to be confident in using the information to inform strategic conversations such as commissioning. Thirdly, channels of communication across the stroke pathway provide opportunities for collaboration around shared goals such as the curation of complete datasets. Finally, audit feedback is more likely to be used for quality improvement if stakeholders perceive it as reflecting the services they deliver and capturing the impact of these services for stroke survivors.
Participants described frustrations with the perceived limitations of existing outcome measures and proposed the collection of an alternative patient reported outcome measure the EQ5D-5L. Statistical analysis of national clinical audit data (n=3,813) confirmed that for community dwelling stroke survivors in England, the characteristics collected by SSNAP were significantly associated with the majority of EQ5D-5L outcomes at the level of domain, EQIndex and EQ-VAS. Characteristics included age, gender, comorbidities, relative deprivation, stroke severity and disability. The EQ5D-5L was found to be more reflective of physical, rather than psychological components of health-related quality of life. However, individual EQ5D-5L domains and the visual analogue scale of overall health provided additional information regarding pain and anxiety, to that already offered by measures collected in SSNAP.
Conclusion
Findings in this thesis add to the existing literature, providing transferable insights into the role of national clinical audit in driving quality improvement in community services. These include the importance of organisational support, such as dedicated administrative support, leadership engagement and the fostering of audit champions in this setting. There was a recognition of the importance of accessible audit feedback to enable its strategic use and the role of collaboration-based approaches along a clinical pathway which span organisational boundaries. The metrics collected should be interpreted by stakeholders as reflecting both the service they deliver and the populations they serve. The collection of EQ5D-5L at commencement of community rehabilitation and again at six months offers additional insights into the needs of stroke survivors at what can be a challenging time in their recovery.
Actions (Archive Staff Only)
 |
Edit View |
Tools
Tools
