Author: Thoshenthri Kandasamy
Kandasamy, Thoshenthri, 2025 From Standard to Excellence: The Pillars of a Centre of Clinical Excellence in Stroke Recovery and Rehabilitation, Flinders University, College of Nursing and Health Sciences
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ABSTRACT
Stroke rehabilitation centres could play a vital role in promoting recovery and improving the quality of life of stroke survivors and their families. Many facets contribute to effective rehabilitation, including coordinated specialised multi-disciplinary teams, ongoing access to rehabilitation, early discharge planning and a goal-oriented approach to care. The concept of a Centre of Clinical Excellence represents an aspirational benchmark in stroke rehabilitation, characterised by exceptional patient care, innovative processes and optimising outcomes. However, there are no clear ways to determine which stroke rehabilitation centres are Centres of Clinical Excellence.
The International Stroke Recovery and Rehabilitation Alliance, in a collaborative effort between researchers and consumers, identified seven defining criteria of Centres of Clinical Excellence (CoCE) in Stroke Recovery and Rehabilitation. This PhD research, which was conducted with the active participation of international stroke rehabilitation centres, was designed to trial and evaluate the seven defining criteria and their underpinning indicators.
This research employed a pragmatic concurrent embedded mixed-method approach to explore the evidence on CoCE and to trial and evaluate the measurable indicators in centres that provided stroke rehabilitation. This method allowed the research questions to be answered from quantitative and qualitative perspectives, allowing for a more complete analysis. Initially, a scoping review was undertaken to explore how CoCE have been identified, developed or described in the international literature. Then, the criteria and indicators of CoCE in Stroke Recovery and Rehabilitation were trialled and evaluated using a survey and semi-structured interview tools that were developed, guided by the Consolidated Framework for Implementation Research (CFIR) as the theoretical framework. Centres were asked whether they were able to demonstrate the performance of each criterion and indicator, and data were collected about participants’ perceptions of the indicators and experiences when gathering information on these. The responses regarding what data were collected at each site were descriptively analysed. Responses regarding perceptions, facilitators and barriers were thematically analysed using the Framework Analysis method and mapped to the constructs from the CFIR.
In total, 12 centres providing stroke rehabilitation services from low, middle and high-income countries participated in this research. Centres were able to demonstrate evidence for most of the indicators from Criterion 1 (Optimising Outcome and Delivering Rehabilitation), 3 (Interprofessional Working and Person-Centred Rehabilitation) and 6 (Receiving and Delivering Education). The least demonstrated indicators were from Criterion 2 (Research Culture), 5 (Leadership) and 7 (Advocacy). Within Criterion 4 (Knowledge Exchange and Mentorship), most centres were able to demonstrate nearly all the indicators in the Knowledge Exchange category but not the Mentorship category.
Overall, the participants from the centres acknowledged that the criteria and indicators set useful benchmarks for aspirational CoCE in Stroke Recovery and Rehabilitation. However, this research found that there were elements that influenced the usability of the indicators at the centres. These elements included the design of the indicators, the existing systems (Meso and Micro level) within and beyond the healthcare centres (Macro level), and the process used to gather and assess information to demonstrate performance on the criteria and indicators. It was noted that the trialling of the indicators highlighted several gaps in service and service delivery, prompting consideration for future service improvement initiatives at the centres involved. Additionally, the results highlighted the priority of different healthcare centres based on socioeconomic status, geographical location and healthcare funding model.
Ultimately, the centres reported that the overarching criteria were relevant and crucial to their stroke service. They emphasised the need for further refinement of the underpinning indicators to improve the usability, which will be a key focus of future research. This research offers original insights into the field of stroke rehabilitation. It provides valuable feedback on the criteria and indicators, paving the way towards establishing a framework for Centres of Clinical Excellence in Stroke Recovery and Rehabilitation. The outcomes from this research will guide the development of a standardised framework for delivering excellent stroke care and outcomes for stroke survivors to establish the aspirational Centres of Clinical Excellence in Stroke Recovery and Rehabilitation at a global level.
Keywords: stroke rehabilitation, stroke recovery, clinical excellence, centres of clinical excellence, mixed method
Subject: Rehabilitation thesis
Thesis type: Doctor of Philosophy
Completed: 2025
School: College of Nursing and Health Sciences
Supervisor: Assoc. Prof. Elizabeth Lynch