This program will seek to implement a quality improvement program to improve the care of Veterans with TIA or minor stroke at 6 Veteran Health Administration Hospitals. The investigators will evaluate the implementation and effectiveness of the quality improvement program.

Aim 1. To develop a quality improvement program to improve the care of Veterans with TIA or minor stroke that can be deployed nationwide. The program will include multiple components: a reporting system that is based on validated electronic quality measures (eCQMs) that will allow staff to monitor the time-sensitive processes of care and outcomes of their population of Veterans with TIA or minor stroke; clinical protocols to improve the timeliness and completeness of care; professional education materials; and clinical note templates for use by nursing and pharmacy staff. Lessons learned at the individual sites engaged in the quality improvement program will be shared across sites by use of a web-based platform and a virtual collaborative. We will assess end user's assessment of the program and its core elements.

Aim 2. To evaluate the effectiveness of the Aim 1 QI intervention program for Veterans with TIA or minor stroke against usual care. Teams at the 6 intervention sites will be given the quality improvement program components. The primary effectiveness outcome is the proportion of Veterans who received all of the guideline-concordant processes of care for which they are eligible referred to as the "Without-Fail" care rate.

Aim 3. To evaluate the implementation of the QI intervention program across the 6 participating sites. The two primary implementation outcomes will be the number of implementation activities completed during the one-year active implementation period and the final level of team organization (defined as the Group Organization (GO Score)) for improving TIA care at the end of the 12-month active implementation period.

Secondary Aim To evaluate the sustainability of the program. Sustainability will be evaluated over a one-year period that begins immediately after the one-year active implementation period. We will compare the Without-Fail rate in the sustainability period to the baseline period and the post-implementation period.

Inclusion Criteria:

• This program will seek VA hospitals that are self-designated as either a VHA Primary Stroke Center or a Limited Hours Stroke Facility or Supporting Stroke Center.
• Eligibility for staff interviews is based on involvement in the QI intervention and willingness to participate.

Exclusion Criteria:

• Unwilling to participate

Investigators interested in examining PREVENT project data should contact the PI, Dr. Dawn Bravata.

There were 6 intervention sites and 36 control sites and two time periods (baseline and active implementation). Different patients were cared for at the sites during the two time periods. During baseline, there were N=162 PREVENT intervention patients and N=973 patients at control sites. During the active implementation period, there were N=189 patients at PREVENT intervention sites and N=968 at control sites.

The active study period for each site was of variable duration ranging from 19-37 months; it began with the baseline interview and ended on September 2020.

Adverse Events were monitored on a hospital level. Facility staff were the subjects of this research, the primary risk was breach of confidentiality which was not observed during the study period.

PREVENT was implemented within VA facilities, which may limit generalizability. There may be diagnostic uncertainty when making a diagnosis of TIA. Because the intervention included multiple components, we are unable to estimate the unique associations of each specific element. Neither site selection nor allocation to waves was randomized. Although a 6-site sample provided adequate power for the detection of changes in processes of care, the study was not powered to detect changes in outcomes.