Authors: (including presenting author): :
Karin Chow (1), Raymond Leung (1), Dr Benny Cheng CP (3), Dr Jimmy Siu (2), Dr Michael FYP (1) , Dr Kelvin Tsoi (1), Dr Carmen Lam (3),Dr Eddie Chow (1), Dr Jeffery Fung (3), Dr Justin Lam (2), Members of TMH Stroke Centre Office (3)
Affiliation: :
(1) Medicine & Geriatrics, Neurology, Tuen Mun Hospital, (2) NTWC Department of Radiology and Nuclear Medicine, (3) TMH Neuroscience Centre
Keyword 1: :
National Stroke Centre Accreditation
Keyword 2: :
Accreditation
Introduction: :
In healthcare management, accreditation can either become a compliance burden or a strategic lever for capability-building. This project demonstrates how preparation for National Stroke Centre Accreditation—delivered as a structured change Programme—enabled sustainable, system-wide transformation.
Objectives: :
Over an 18-month readiness period, our institution redesigned governance, pathways, and workforce systems and achieved designation as the first National Stroke Centre in Hong Kong, confirming both the rigor of implementation and the maturity of the redesigned model.
Methodology: :
Accreditation preparation was organized across nine core domains: governance and management; green channel operations; neurology; neurosurgery; interventional treatment; neuro-intensive care; rehabilitation and secondary prevention; health management; and data platform governance. This structure created clear accountabilities, standardized multidisciplinary protocols, and strengthened performance oversight. A time-critical “green channel” for intravenous thrombolysis was implemented to streamline decision-making, imaging, and treatment activation. Regional integration was advanced through structured networking support to two peripheral hospitals, including agreed transfer pathways and operational alignment for thrombectomy candidates. Strategic planning and workforce development were rebuilt with annual goals and action plans for each stakeholder, supported by standardized training systems. Prevention capability was broadened by redefining high-risk populations and extending screening initiatives (including carotid Doppler ultrasonography) beyond acute stroke units into endocrine and cardiac units—an approach not previously undertaken.
Result & Outcome: :
Results: The Programme produced substantial improvements in hyperacute timeliness. Median door-to-needle time (DNT) decreased from 71 minutes (2023) to 44 minutes (2024) and 41 minutes (2025), with a fastest recorded DNT of 18 minutes. Reliability improved in parallel: the proportion of patients achieving DNT ≤45 minutes increased from 5.8% (2023) to 53.9% (2024) following green channel implementation, and further to 57.8% (2025). Door-to-puncture time (DPT) for intra-arterial thrombectomy improved through integrated pathway design and inter-hospital coordination, with median DPT reduced from 212 minutes (2023) to 87.5 minutes (2025) (for non-transfer-in case). Conclusion: National accreditation, when embraced as a management framework for staff engagement, shared governance, and system integration, can rapidly elevate time-critical performance and enable sustainable service transformation. Our experience provides a scalable model for stroke systems seeking to couple clinical growth with operational reliability through structured standards, multidisciplinary empowerment, and data-enabled accountability.
