Back on track: a case study on sustaining and reducing stroke treatment times in a medium-sized Norwegian hospital

BACKGROUND: Sustaining continuous improvement (CI) in healthcare organizations remains challenging, particularly in settings characterized by disciplinary silos. Although many initiatives achieve initial improvements, less is known about how improvement efforts are sustained, decline over time, or become revitalized. This study examined the long-term development of a cross-disciplinary stroke care improvement initiative in a Norwegian general hospital. METHODS: We conducted a diagnostic single-case study of a cross-disciplinary improvement initiative in stroke care. Data were collected over an extended period (2013-2024) and included participant observations, internal documents, and performance data (door-to-needle times), as well as six semi-structured interviews with members of the interdisciplinary improvement group. Data was analyzed using reflexive thematic analysis, supported by triangulation across data sources and iterative discussions among the authors. RESULTS: Initial reductions in treatment times were associated with the development of cross-disciplinary structures, including a shared care pathway, continuous performance feedback, and team-based organization. A subsequent decline in performance appeared to be linked to personnel changes and reduced improvement activity. Improvement efforts were later revitalized through simulation-based training and renewed practitioner engagement. The analysis identified three interrelated themes: (1) development of practitioner ownership, (2) establishment of cross-disciplinary structures, and (3) the role of these structures in enabling the revitalization of improvement efforts. CONCLUSIONS: This study suggests that sustaining continuous improvement in cross-disciplinary healthcare processes depends on the interaction between practitioner engagement and organizational support structures. Declining performance was caused by reduced improvement activity, personnel changes, and weakening practitioner ownership. At the same time, established cross-disciplinary structures - such as performance feedback, shared care pathways, and team-based work - enabled recognition of these problems and supported subsequent revitalization efforts. While the empirical findings are case-specific, the study highlights the potential value of a diagnostic approach for identifying and addressing breakdowns in continuous improvement processes in and beyond healthcare settings.