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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282XOn-line version ISSN 1678-4227

Arq. Neuro-Psiquiatr. vol.73 no.11 São Paulo Nov. 2015  Epub Oct 06, 2015 


Improvement initiative in stroke care

Iniciativa em melhoria da assistência ao AVC

Gabriela Salim Spagnol 1  

Lenise Valler 2  

Wagner Mauad Avelar 3  

1Universidade Estadual de Campinas, Faculdade de Ciências Médicas, Campinas SP, Brazil;

2Hospital de Clínicas, Unidade de Terapia Intensiva Neurológica, Campinas SP, Brazil.

3Universidade Estadual de Campinas, Grupo de Pesquisa em Neurovascular, Campinas SP, Brazil.

We read with interest the article by Li and Johnson1 in which they demonstrated that improvement initiatives were able to reduce alarm-to-needle time in acute stroke care by applying the Lean Six Sigma approach. In Brazil, the Unified Health System is challenged to improve efficiency with limited budgets by ensuring that the right things are done by the right people at the right time. Successful implementations in the National Health System2 (United Kingdom) have shown that Lean thinking contributes to improve daily processes, eliminating waste and focusing in what really matters for the patient3.

In the Hospital de Clínicas at University of Campinas, together with a multidisciplinary team, we started an improvement initiative in stroke care. Instead of jumping into quick-fix solutions, neurologists, researchers, a nurse, a physiotherapist and a secretary were gathered to analyze the current status of the Neurology Outpatient Clinic. According to Kahneman4, winner of the Nobel Prize in Economics, people tend to identify problems and jump into solutions. He explains the two systems that drive the way we think: System 1 is fast, intuitive, and emotional; System 2 is slower, more deliberative, and more logical.

In order to engage the most efficient system of thoughts, we applied the SWOT analysis. Service perspectives were shared in sticky notes, strategically placed on posters under each of the four SWOT categories: Strengths, Weaknesses, Opportunities and Threats. Two groups of 3-4 participants were given five minutes to list those items, interspersed with two-minutes-presentations between rounds5. Different members presented in each round, assuring full engagement of both groups. Afterwards, they agreed upon priorities to design a strategic plan in the next workshop. Within this 80-minutes workshop, endless problems and nightmares were transformed into a clear pathway for an effective group effort in service improvement. Changes in the mindsets of medical and administrative staff will create capacity for better services and establish collectively new, efficient and effective ways for delivering care2. After all, 'time is brain.


Li LM, Johnson S. Lean thinking turns 'time is brain' into reality. Arq Neuropsiquiatr. 2015;73(6):526-30. doi:10.1590/0004-282X20150047. [ Links ]

Souza LB. Trends and approaches in lean healthcare. Leadership in Health Services 2009;22(2):121-39. doi:10.1108/17511870910953788. [ Links ]

Li LM, Johnson S. Stroke care within the golden hour. JAMA Neurol. 2015;72(4):475. doi:10.1001/jamaneurol.2014.4568. [ Links ]

Kahneman D. Maps of bounded rationality: psychology for behavioral economics. Am Econ Rev. 2003;93(5):1449-75. [ Links ]

Perera R, Peiró FP. Strategic planning in healthcare organizations. Revista Española de Cardiología (English Edition) 2012;65(8):749-54. doi:10.1016/j.rec.2012.04.004. [ Links ]

Support: full MSc scholarship provided by FAPESP to Gabriela Spagnol. Grant Number: 2013/26353-7.

Received: June 30, 2015; Accepted: July 21, 2015

Correspondence: Gabriela Salim Spagnol; FCM, UNICAMP; Rua Vital Brasil, s/n, Prédio Vital Brasil, Sala 17; Cidade Universitária, Barão Geraldo; 13083-970 Campinas SP, Brasil;

Conflict of interest: There is no conflict of interest to declare.

Role of the funder/sponsor: The funder had no role in the preparation, review, or approval of the manuscript, and the decision to submit the manuscript for publication.

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.