"Growing A Stroke Center Chunk By Chunk"

Creating a world class stroke program by facilitating self-organization and emergence.

A Story from Saint Luke’s Hospital, Kansas City, MO
Told by: Ken Baskin, Jeffrey Goldstein, and Curt Lindberg

Illustration of:

• self-organization
• emergence
• complexity lens
• generative relationships
• tune to the edge
• multiple actions
• chunking
• good enough vision
• competition/cooperation

At a time when financial results have become as important as clinical outcomes, it’s hard to argue with the results of the Stroke Center at Saint Luke’s Hospital in Kansas City, Mo. In its first five years, the center:

• reduced the average hospital stay for stroke victims from 9.6 to 5.6 days;
• increased its use of thrombolytics from three patients in 1993 to 60 in 1999;
• saw total admissions for stroke move up 15 percent a year, with stroke warning admissions up 50 percent in 1999 alone;
• enabled stroke care to drop from the hospital’s "DRG Top 20 Loser" liSaint

Yet for Marilyn Rymer, M.D., the staff neurologist who has spearheaded this effort since it was first suggested to her early in 1993, these results only begin to indicate how successful the center has been. "I’ve never worked with people who are more excited about doing their jobs or happier to come to work every morning," she explained. "Doctors from other groups comment on how happy our people are. Everyone is having a good time doing jobs that could just as easily seem like drudgery. For me, that’s even more remarkable than the results we’ve achieved, because I’m not sure we could have generated such good numbers without our people’s enthusiasm."

How did the enthusiasm Rymer spoke of generate good numbers? That enthusiasm reflected an open environment where everyone was encouraged to contribute. And because this openness extended throughout the hospital and into the community, the center attracted the wider range of ideas and increased feedback from the hospital and community that have made it successful, both financially and in terms of patient outcomes.

Interestingly, the Stroke Center’s evolution seems a close match to what Complexity Theory suggests would have been the best way to develop it, even though Rymer didn’t start learning about the subject until the Stroke Center was well under way. For instance, rather than initiating the center traditionally, with a detailed plan implemented through command-and-control, Rymer enabled the Stroke Center to evolve as a complex adaptive system. Such systems, studied at research centers as the Santa Fe Institute, include molecules, living things, weather systems, organizations, and the economy. What unites such very different entities is a set of principles that are generating a revolution across many scientific disciplines and are now receiving serious consideration by organizational theorists and practitioners.

For one thing, Rymer enabled the center to evolve as a complex adaptive system, guided by the interactions of a team that included people with experience, not just in neurology, but also in fields such as nutrition and physical therapy. By encouraging these team members to contribute to the development process, Rymer enabled the center to continually adapt to the variety of medical and cultural conditions at Saint Luke’s. The result was, on one hand, an ever-improving process of caring for stroke victims, as reflected in shorter hospital stays and better financial numbers. On the other, Rymer’s approach created a sense of ownership among the team that set the stage for the positive workplace experience of which she is so proud.

Similarly, the Stroke Center became a reality with an "effortlessness" that still surprises Rymer. No resistance. No pitched battles. Call it "serendipity" or "synchronicity," but, over and over, events in the history of the stroke center fell together with an apparent lack of effort. "The entire project seemed to self-organize, with surprisingly little effort on our parts, just as the literature in complexity theory indicates," she explained. This idea of self-organization is basic to complex adaptive systems. When conditions are right, they adapt, reorganizing themselves without a top-down control mechanism directing them. Entities that self-organize seem to be especially effective at adapting to rapidly changing environments.

Self-organization suggests that if people in an organization are given the freedom and information they need, they will be able to adapt to changing conditions better than if their behavior is closely managed and directed. For most "hardheaded" managers, this idea of self-organization at first seems baffling. After all, it’s the opposite of what business schools have taught us for decades. Yet, the story of the Stroke Center at Saint Luke’s clearly illustrates the power of self-organization to achieve the kind of results health care organizations so desperately desire today. With these results, even the most hardheaded manager has to wonder whether encouraging organizational self-organization isn’t just plain good sense.

Openness and Inclusion

The story of the Stroke Center began one day, early in 1993, when Joe Pinkerton, then president of the medical staff at Saint Luke’s Hospital in Kansas City, Mo., was talking to Rymer after a meeting of the hospital’s leadership group. Pinkerton suggested that creating a Stroke Center could benefit the hospital in many ways. Care for stroke patients, after all, had traditionally been high volume, high cost, high risk, and high loss. Stroke is the third leading cause of death and the leading cause of adult disability. Saint Luke’s alone had 400 to 500 stroke or stroke-warning patients passing through every year. Yet, they were scattered all over the hospital, and the multidisciplinary treatment stroke demands often resulted in miscommunications among different disciplines. Moreover, stroke treatment consistently lost money for Saint Luke’s. A dedicated stroke center, Pinkerton suggested, might benefit both stroke patients and the hospital.

Rymer agreed to champion the project. Yet, in spite of its potential benefits, there would be obvious problems in getting such a center up and running by a traditional top-down, command-and-control style. If only because so many units within the hospital would have to cooperate, it was clear its success would require a different management style.

By bringing in so many points of view from the beginning, Rymer opened communications loops with people all over the hospital. As a result, the center would evolve in the type of information-rich environment in which complex adaptive systems tend to thrive, including anyone who wanted to contribute, rather than merely telling people what to do.

The task force, the core of what would become a stroke team, in which new members would come and go as their expertise was needed, included seven members. In addition to Rymer, they were:

• Debbie Summers, a clinical nurse specialist;
• Ann Kelley, a nurse manager in intensive care and neuroscience;
• Duane Thrutchley, a nurse in home care with computer graphics abilities;
• Shiela Luetkemeyer, a program coordinator with rehabilitation;
• Margaret Welch, a nurse in neurosurgery;
• Connie Erb, liason staff to the Saint Luke’s Foundation; and
• Martha McCracken, social worker for the neuroscience and rehab units.

The task force reviewed the literature, looking for best practices, and discovered there was no easy model for what they wanted to do. Still looking for a model, Rymer visited the dedicated Stroke Center at the University of Virginia (UVA) Hospital, travelling with Saint Luke’s Chief of Operations, Pat Soper. They concluded that, while some elements of the UVA stroke center might be valuable, Saint Luke’s would largely have to develop procedures and structures unique to itself. Typically, academic stroke centers, such as the one at UVA, are research driven. Saint Luke’s, on the other hand, wanted its stroke center to be clinically excellent, but with research and education arms.

Because they felt compelled to create their own model, Rymer and the Stroke Center team could remain true to a self-organizing approach. They would be able to build an operation that fit with Saint Luke’s history and culture, unlike some efforts where benchmarking results in procedures that don’t quite fit the culture of the hospitals that adopt them. In this way, the center would evolve by adapting to the specific conditions it encountered, as research into complex adaptive systems suggest, rather than to a predetermined set of specifications.

Evolution vs. Revolution

One key element that would become central both to the project’s open management style and its evolutionary development was the critical path that Soper had helped develop for treating stroke even before Pinkerton spoke to Rymer about the center. "Critical paths detail the procedures for dealing with a specific condition," Soper explained. "We’d had some critical paths for a while, like the one for treating stroke, but no one took responsibility for teaching and explaining them. No one was championing them." So, in 1992, Soper, then chief of nursing, became the hospital-wide champion for critical paths.

"My approach was to work with a departmental team to develop the critical path," she noted. "That team is the key to success. Anyone can write a path and hand it to clinicians. But they won’t use it if they don’t believe it belongs to them. That’s what had happened to the critical path for treating stroke: We had one that wasn’t being used. Today, I work to help the teams that will be using the paths to develop them. Then, I get out of the way." As a result, the stroke path continues evolving according to members’ inputs and organizational exigencies, producing ever-improving treatment.

Because a critical path can shift, creating more effective processes as the people in them learn more, the stroke path complemented Rymer’s non-traditional approach, letting the center evolve, rather than introducing it as an "earth-shattering" new structure. This was an evolutionary approach — what Evolutionary Biologist Ernst Mayr calls "proximate logic," by which species evolve by building on existing structures, rather than through radical change. At the same time, recombining old structures can result in very novel configurations.

By taking a similar approach, Rymer further enabled the center to draw strength from, and then adapt to, the existing hospital environment.

To optimize this evolutionary approach, Rymer made the team meetings a "safe" place, where everyone could expect support in examining any idea, no matter how unformed when it was first mentioned. To that end, she instituted a rule that nothing said at team meetings could be taken out of the room. "Because we were always ready to entertain new ideas, we could always be on the lookout for better ways of doing things," noted Thrutchley. "It was exciting just to see what surprises might be in store at any meeting."

In terms of complex adaptive systems research, these team meetings enabled the system to take advantage of spontaneous events, sometimes called "noise." Traditional managers often dismiss such "noisy" information as irrelevant, because it doesn’t fit neatly in a predetermined plan. Yet, noisy information can be just the thing a system needs in its ongoing evolution — a source of new ideas and information about unexpected conditions, what is really going on, rather than what management thinks should be going on. As a result, a management style grounded in complexity theory acknowledges the value of such pieces of unexpected information. By recognizing and incorporating this "noise," organizations managed as complex adaptive system are better able to evolve to meet the shifting needs of their environments. Unlike traditional management, where "noise" is something to be tuned out, like static on a radio, in organizations managed to be self-organizing, such "noise" provides much of the unanticipated feedback that drives its evolution.

Principles
Multiple actions
Chunking

The idea of a stroke SWAT team, for instance, emerged just this way, during a stroke team meeting attended by Chuck Weinstein, MD, a neurologist in practice with Rymer. Weinstein mentioned a stroke case that occurred to a patient in the hospital for another condition, where he’d been called in too late for an intervention to produce the best possible outcome. As the team’s research had discovered, outcomes are generally better for people who have their strokes out on the street than in most hospitals. For one thing, the fragmentation by discipline that traditionally characterizes hospitals can make it difficult for physicians and nurses in other departments to respond quickly. In many cases, symptoms of stroke are also symptomatic of other conditions, and providers will naturally interpret those signs, in a patient who is in the hospital with a respiratory condition, for example, as further signs of that condition.

A traditional management approach might have rejected Weinstein’s feedback as mere "noise," not valuable information. The core team, on the other hand, created the idea of a SWAT team that would be responsible for helping nurses and physicians throughout the hospital identify potential in-hospital stroke victims quickly.

On another occasion, a physician from the Emergency Room sat in on a meeting and helped open communications between the stroke center and the ER. Because so many stroke victims come to the hospital through the ER, that communication is extremely important. On still another occasion, Hilda Fuentes, vice president of Diversity at Saint Luke’s, pointed out that Kansas City had a large Hispanic population with a high risk of stroke. As a result, much of the center’s educational literature is now available in Spanish as well as English. By not rejecting such ideas as mere noise, the team continually enriched the center’s ability to meet its goal — taking better care of stroke victims in the Kansas City area.

In addition, the environment of openness created another benefit. Because all the team members were contributing to a new way of taking better care of patients, they generated enormous amounts of excitement and energy for the jobs at hand. "We spend a lot of long days examining these issues and doing the grunt work to make things happen," Kelly explained. "But we all developed such a love for what we were doing that we were willing to take on any task. If it ever stops being fun, I’m getting out." In many ways, it was this sense of ownership through contributions that created the environment of happiness and excitement Rymer is so proud of.

Unlike a traditional bureaucracy, where everyone expects new ideas to come from the top of the hierarchy, control at the stroke center was distributed to encourage the flow of more and better ideas. In Rymer’s words, "The key for us is always to take better care of stroke victims. We wanted to hear from anyone who thought she could help us meet that goal." Such distribution of control, so that the system’s evolution doesn’t rest solely in a hierarchy’s top level, is characteristic of complex adaptive systems.

Complex Functions of the Critical Path

As it turned out, the center’s critical path created a number of benefits. For one thing, it gave team members an internal benchmark on which to improve. For example, Thrutchley, then a stroke team nurse, noted that patients need to start eating within 24-48 hours after being treated. Yet the existing critical path had too many steps between the decision that a stroke patient needed a swallogram and the time it was administered. Discussing issues such as places where the path could be improved by eliminating steps, in addition, gave nurses on the team the opportunity to suggest improvements in treatment that they might have been uncomfortable making directly to physicians.

In this way, the critical path evolved much like the center. Beginning with an existing structure, the path Soper had helped develop grew and adapted through the feedback loops between the path, suggestions from hospital staff members, and actual patient care. "We were always ready to change the way we did things," Summers noted, "and we made a lot of changes because we were continually listening to nurses and patients." Moreover, the evolving path provided a vehicle for incorporating noisy information, such as Fuentes’ suggestions about the area’s Hispanic population.

Such feedback loops are essential to the ability of all complex adaptive systems to continually adapt to changing conditions. The beauty of this way of introducing improvements is that none has to be earthshaking. Every minor improvement builds on the others, and the treatment documented in the path continues to evolve. As a result of such "minor" changes, the team’s focus over the first two years it was together, they were able to streamline the procedure for treating stroke patients, which resulted in the one-third decrease in average stay for stroke at Saint Luke’s.

Not only is the critical path flexible in that it evolves, its flexibility also reflects the way about one in five stroke victims "fall off" the path during recovery. This form of flexibility serves two functions. It enables nurses working in the center to remain aware that some stroke victims will require individualized treatment. It also serves as a warning, when too many victims fall off the path, that the path, itself, may need revision. As a result, Rymer likes to talk about the path being "a tool, not a rule."

Finally, the critical path became a boundary for the self-organizing efforts of team members — that is, it provided a space in which the self-organizing stroke center could operate safely, at the same time channeling the creativity of all its members. This is exactly what research into complex adaptive systems has demonstrated, that self-organization requires an arena, or "container" with boundaries that serve to channel creative energies and keep the system intact. As a result, with the path, physicians and nurses no longer had to worry about missing a critical step in treatment. Every time they performed one, they could check it off on the path. This freed them to focus much more of their attention on what they could do to continue improving those procedures. In effect protected by the path, they could act more autonomously without having to worry about mistakes that might hurt their patients, as long as they observed the path.

Advantages of Openness

Another advantage of the openness that characterized the stroke team was the dedication it fostered in all its members. Summers put it this way, "Don’t ask us what we can do if you don’t want us to do it. When we realized the delay in treatment for people who had strokes in the hospital, we went to the medical committee with plans for addressing it. We told them about the SWAT team and how we expected it to work. Only one physician said he didn’t want his patients ‘SWATted.’"

Because the Stroke Center team was inter-disciplinary, its members got used to thinking of treating stroke systemically, across all the boundaries that can make things so difficult in many bureaucracies. As a result, they soon realized that education and cooperation would be essential for a variety of groups — in the hospital, in the Kansas City health care community, and in the wider community as a whole. Their realization of the advantages of the center being vitally connected to its environment is reflected in studies of complex adaptive systems. Such systems can thrive only when they exchange enough energy and information with their surroundings to be able to adapt effectively.

Most pressing was the need to get the Emergency Room (ER) nurses and physicians, and the Emergency Medical Technicians (EMTs) working with the Stroke Center team. After all, most people with strokes come into the hospital by way of the ER; yet, some people ended up sitting there for several hours before physicians diagnosed them. "We would especially need the ER people for the tPA trial," Rymers noted. The EMTs, she added, can identity up to 70 percent of stroke victims, once they understand how to test for arm/face movement and speech disability.

Stroke Center team members started telling people in the ER about both the new services and needs of the newly opened center. Any initial defensiveness disappeared after Rymer’s "Stroke Talk" columns appeared in ER’s internal newsletter. "From that time on, the ER people got increasingly engaged," noted Summers, who did most of the education there. "The nurses and EMTs can talk our language. They knew which questions to ask. I was very gratified to see the kind of positive reinforcement our conversations generated. We all increasingly recognized how much we needed each other." As a result, both Stroke Center team members and people in ER were able to redefine their procedures in terms of mutual benefit. Since that time, the quality of cooperation has continued high.

Self-Organization via Growing Connections with the Environment

Self-organizing, complex system grow by making more and more connections with their environments. Similarly, as it grew, the center was becoming more inter-disciplinary. At one point, stroke center team members began conducting sessions that included people in neurology, rehabilitation and speech therapy. "It was exciting to be the first group to do inter-disciplinary education," Summers said. "In one case, we set it up so that we could conduct two days where people in all the disciplines were talking." By doing things such as bringing in stroke victims to discuss their experiences, the team was able to begin building the kind of commitment its members felt in people throughout the hospital.

The spread of linkages between the stroke center and its environment went beyond Saint Luke’s. The team would also have to educate a series of audiences in the community. For one thing, the signs of stroke weren’t widely understood in the community, even among the elderly with a high likelihood of having one. "After the fact, people in a victim’s family say they wish they’d known more," explained McCracken, the social worker on the team. "But during the crisis, they find it difficult to take in information." Beyond this, Thutchley, the nurse who heads up the home care program, said that 20 to 23 percent of those with acute strokes require home care after their rehabilitation. "Victims and their families need to know a variety of things, from the availability of Medicare-covered assistance to how to prevent recurrence," he pointed out.

To meet these community education needs, the team developed a series of programs that its members run. Kelly, nurse manager of the Stroke Center, appears at "Healthy Break" sessions, where she talks to people in the workplace, to raise awareness both about stroke and about what the center can do. Margaret Welch, a stroke team nurse, conducts a variety of community education programs, with special emphasis on the senior community. Those programs range from appearances at retirement homes to contributing articles in their internal newsletters and making flip chart presentations in clinic exam rooms. Luetkemeyer, who coordinates the stroke center’s work with rehabilitation, works directly with families of stroke victims and encourages their participation in stroke survivor support groups sponsored by the American Heart Association.

As with so many facets of the center, its involvement with all these programs wasn’t planned in detail and then executed. "At first, we didn’t even know what victims and their families understood," Thrutchley noted. "We learned that most families members insist they want the victim to recover at home, no matter what. Yet they had little idea about issues such as how to prevent recurrence or what is involved with rehabilitation.

"That made it absolutely necessary for us to begin from ground zero, first to learn what information these people would need and, second, to tailor programs that would meet those needs," he added.

The final element of community education has been in the Kansas City medical community. "We wanted our center to be the hub of an area-wide effort to address the issues surrounding stroke treatment," Rymer noted. "That means we have to present ourselves as a resource that different area hospitals can use differently.

"At first, we had to get a lot of information to hospitals and physicians," she continued. "Obviously, if other hospitals don’t know about the services we can offer them, they can’t take advantage of our resources. We’ve also worked to explain the new approaches we’re taking. It used to be that physicians didn’t have to do anything for the first 24 hours after a person had a stroke. Now, with the new thrombolytic drugs, it’s often important to respond within the first couple of hours."

The center has also worked to help ambulance drivers understand when to take stroke victims to Saint Luke’s for its advanced treatment. "Patients can request a specific hospital when the ambulance picks them up," Rymer said. "Otherwise, the driver will immediately take them to the nearest hospital."

Rymer’s ideal is to create a network of relationships with hospitals in the area, offering the stroke center’s resources to help each develop a plan to optimize its stroke treatment. "Some stroke victims can be treated at other area hospitals; other victims need the treatment we alone offer," she explained. "For instance, we work with rural hospitals that can’t perform CT scans 24 hours a day. We have two CT scans available around the clock. And we have a helipad so that stroke victims can be brought to us as quickly as possible."

Finally, the stroke team offers training to other area hospitals based on its hands-on experience in developing Saint Luke’s stroke center. "We want to be flexible so that we can address the specific needs on other hospitals," Rymer explained. "Some hospitals want a dedicated stroke center for acute care. Others look to state-of-the-art treatment without dedicated beds. Still others prefer a comprehensive, full-spectrum program. We want to help each accomplish its goals."

As a result, the Stroke Center will help other hospitals assess their training needs and put together a package that may include any of a number of activities. Those activities can include information on planning a stroke program, designing a center, developing a stroke team, choosing the appropriate treatment tools, managing data and outcomes, exploring research opportunities, or sustaining support of the hospital administration and board.

Once again, this plan for helping other hospitals wasn’t part of a master plan created at the inception of Saint Luke’s Stroke Center. Rather, it emerged as a need in the course of the center’s operations and was developed according to information coming in through a variety of feedback loops.

A Case of Serendipity

Perhaps the most surprising example of self-organization in the six-year history of the center began in the early planning phase in 1993, when one of the public relations people involved suggested that the team would know the center was a success when it was profiled on Good Morning, America. Everyone had a good laugh.

Jump forward four years. It’s November 1997, and Peter Kilborn, a financial reporter for The New York Times, stood in Saint Luke’s emergency room, observing whether managed care was limiting procedures health care providers wanted to perform. While Kilborn was standing there, a helicopter arrived with an 83-year-old stroke victim. The reporter followed the victim through his treatment with intra-arterial urokinase, destroying his clot. Within an hour and a half from his arrival, the patient’s clot was gone and blood flowing naturally to his brain. The stroke’s damage had been largely erased.

So when Kilborn returned to New York, he filed a story of the stroke center, in addition to his story on managed care. When the people at prime-time TV news show 48 Hours read Kilborn’s story, they decided to profile the center and Rymer, its director. That story was aired in April, 1999, and the stroke center team now joked that 48 Hours was great! Look out Good Morning, America. This is serendipity, par excellence!

Thus far, the stroke center has been a major success. Not only has it reduced the average length of stay for stroke victims by over forty percent, the DRG for stroke is so low that, when the center opened, stroke treatment had been the second-worst revenue loser for Saint Luke’s. Today, the hospital nearly breaks even. Moreover, the center has significantly enhanced the hospital’s reputation, with visitors from as far away as Russia and Sweden. Finally, team members regularly make presentations at national conferences, most recently at the 1999 International Stroke Conference of the AHA and the 1999 North American Stroke Association Meeting. At such gatherings, they can network with others on the frontier of stroke treatment and bring back the latest new.

As a result of all of this, Time magazine recognized Saint Luke’s stroke center as one of the top seven in the country (Feb. 15, 1999). The team also recently spent eight days with a crew from the Discovery Channel, working on a documentary on stroke.

Yet, while the center has been just as successful as any of its team members had imagined, the team continues to adapt. "We’re doing a number of things, right now, to ensure that the center survives," Rymer explained. "For instance, we are planning a Stroke Fellowship to build the center’s staff and to offer an opportunity for young physicians to experience how a successful stroke program works."

This continual adaptation is exactly what you’d expect from an organization living at what Complexity Theory literature calls, "the edge of chaos." Throughout its brief history, Saint Luke’s Stroke Center has positioned itself in that region, the area where loose structure permits maximum creative possibility. The reason everyone in the center could enjoy working there so much was that they had the freedom to continually improve its procedures, to contribute what they believed was important. Through her use of this kind of management style, Rymer was able to bring out a variety of ideas that would have been unlikely if the center had been planned more traditionally. The result has been the surprising sense of self-organization in which opportunities seemed to present themselves at just the right time, as the center moved extremely quickly from an interesting idea to a working reality.

Concluding Remarks: Self-Organization Is Not Laissez-faire Management

While the leadership that promoted self-organization at Saint Luke’s Stroke Center is a far cry from traditional command-and-control, it isn’t laissez-faire management, either. With laissez-faire management, top management backs away to the point that it abdicates decision-making authority. The self-organization at the stroke center, on the other hand, required leadership that created the conditions in which people could work toward a common goal without being directed. In this way, everyone who participated on the stroke team shared the decision-making authority. While no one person has all the authority, their shared authority may actually be one of the forces holding people together.

By enabling stroke center personnel to define their direction by working together, the stroke center became a powerful example of how an organization can function naturally, as a complex adaptive system. First, it started small and gathered momentum as energies became focused and it connected with other systems within the hospital and outside. Second, the center took advantage of noise and serendipity. Traditional control systems are generally designed to do the opposite — that is, to dampen or eliminate noise and ignore unanticipated events. The stroke center, on the other hand, evolved feedback mechanisms so its members could listen to the noise and incorporate insights that noise provided. The center also profited by taking advantage of serendipitous events as they occurred. Third, the center evolved according to proximate logic, building on already existing structures and relationships, rather than being pre-designed and introduced as a radical change. This last point is especially important: Because Saint Luke’s didn’t impose a grand design on the people who would operate the center, little resistance was generated, and whatever came along could be used to further the evolution of the system.

For example, at the end of 1993, not one, but two experimental thrombolytic drugs, for breaking up the blood clots that cause stroke, were becoming available, even though their availability had nothing to do with the decision to create the stroke center. If administered soon after a stroke, these drugs have the power to reverse or eliminate the debilitating effects of this condition. One new drug, tPA, was being studied in several storke centers across the country, including the University of Cincinnati. Through Rymer’s contacts, Saint Luke’s was designated one of Cincinnati’s 12 satellite test centers. At about the same time, Saint Luke’s had hired an interventional neuroradiologist, Dr. Lee Graham, who’d been researching intra-arterial urokinase, another thrombolytic. As a result, during the tPA trials, Stroke Center personnel were building experience they could use in testing the effectiveness of the urokinase. Time after time, such opportunities to enhance the Stroke Center’s effectiveness appeared, by coincidence rather than design, and at just the right time.

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