Poster Presentation Smart Strokes Annual Scientific Meeting 2025

From Audit to Action: Strengthening Stroke Rehabilitation Care Through Interdisciplinary Collaboration (#115)

Emma Playfair 1 , Petria Carter 1 , Peter Thompson 1 , Melissa Cooper 1 , Andrew Murray 1 , Kristina Campana 1
  1. General and Neurological Rehabilitation Unit, Prince of Wales Hospital, South Eastern Sydney Local Health District, Randwick, NSW, Australia

Introduction: In 2024, our inpatient rehabilitation unit participated in the National Stroke Rehabilitation Audit, which identified key areas for improvement in goal setting, discharge care planning, and psychosocial assessment. In response, we established interdisciplinary working groups (also targeting care conference documentation and the evolving Stroke Coach role) to strengthen person-centred stroke care, and align more closely with national standards.

 

Methods: An interdisciplinary quality improvement initiative was launched in response to the audit findings, involving allied health, nursing, and medical staff in the following focus areas:

  1. Mood Screening and Broader Psychosocial Assessment
  2. Goal Setting
  3. Care Conference Templates
  4. Discharge Care Plan
  5. Stroke Coach Role Definition

The initiative was coordinated through a central committee using facilitated workshops, bringing together clinicians and consumer feedback to share insights, review practice, identify barriers, and co-develop practical tools. Feedback loops through surveys and informal interviews assessed feasibility, burden, and value.

 

Results: Key outputs to date include:

  • Redesigned goal-setting process to facilitate patient-led, functional goals
  • Re-structured Care Conference templates
  • A broadened psychosocial screening framework beyond mood
  • A prototype Discharge Care Plan, with feedback gathered from patients and staff regarding the workload burden and value
  • A draft Stroke Coach role description, clarifying responsibilities across inpatient and discharge pathway

 

Conclusion: The methodology reflected a real-world quality improvement approach, combining audit feedback with frontline co-design to drive sustainable change.

 

Relevance to Clinical Practice or Patient Experience: This initiative supports more consistent, collaborative, and person-centred care by addressing known gaps in our stroke rehabilitation practice. The redesigned tools and role clarification aim to enhance communication, streamline discharge planning, and ensure patients are more visible and involved in their care journey. Early feedback suggests improved team clarity, reduced duplication, and greater alignment with best practice standards — all of which directly impact patient experience and care quality.