About the Project


Stroke Pathways is an two-phased research project to improve stroke outcomes by taking a system design approach to health care delivery. The project was conducted at the Harvard Design School during 2005-2008, under the leadership of Professor Marco Steinberg. The Strategic Design phase produced three distinct bodies of knowledge:

1. A methodology for looking at complex systems

2. A comprehensive & strategic roadmap to better outcomes at lower costs

3. Identify and defining the "top 10" opportunities for improvement

In the process we've developed:
a "zero footprint" organizational model to collaborate across institutions and specialties
a "strategic design" framework to create change opportunities
a "system change" innovation model (outlined in our activity map below)

Activity map- our system innovation model

Activity map- our system innovation model

A Design perspective to "big picture" problems


Our society has been served well by deep and narrow specialties, but the nature of today’s “big picture” challenges fall at the intersection of what we know. Not unlike cooking, the solution today is not in any one ingredient, but in the mix.

Because key decision makers cannot always see a complete synthetic whole, they are often blind-sided by the unintended consequences of their action. As an integrative discipline, design is uniquely position to fill this strategic need.

Our work leveraged our unique skill-set to: Ask questions at different scales, because different scales provide unique insights; Examine problems in different contexts and from different perspectives, to understand their relative value; Involve stake holders and make our project their project; Create frameworks to integrate complex, and frequently contradictory, problems; Visually represent complex, multidimensional issues to enable a productive problem-framing; Bring to bear our ability to work with indeterminacy and relative precision.

Rather than provide good solutions to the wrong problems, our strength lies in asking the right questions.

Monday, May 26, 2008

Stroke and Strategic Design

When we looked at the current system for stroke care, we identified two fundamental problems: It is set up to deliver a standard range of care for individual needs and it does so within a fragmented delivery system that varies by region, city, hospital and physician. All of these fragmented activities occur in separate realms driven by their own internal logics. Strategic design is a critical new perspective for stroke care. Current care improvement efforts focus on policy or on process improvement. Without a strategic component, even excellent tactical approaches may simply make poorly conceived care principles more efficient.


  • A full care cycle approach to care-innovations (prevention, acute therapy, long-term needs)
  • A systems approach to care delivery, focused on strategic improvements
  • A design-centric approach to problem solving

Improved patient outcomes (mortality, morbidity, quality of life) at lower costs


Our work delivered the following

1. A methodology for looking at complex systems
2. A strategic roadmap to improving outcomes at lower costs

3. Defining the “top 10” areas of opportunity for improvement

and we are currently developing

4. Pilots to demonstrate effective improvement
5. A methodology defining the science of implementation

Our "TOP 10" System improvement opportunities

Our system design approach looked at stroke from a full care cycle perspective. We defined this into three distinct but interrelated phases:

1. Before a stroke (includes prevention)
2. Acute
3. After a stroke (includes rehabilitation and long term needs)

The diagram shows our framework overlaid with the opportunities.

Click on image for closer look

North Carolina Pilot

We are currently working to implement a unique care delivery system in the heart of America’s Stroke Belt that would improve stroke outcomes, reduce costs, and extend the reach of care to underserved communities in North Carolina while building a replicable model nationwide.


North Carolina has the 4th highest stroke mortality rate in the nation (twice the national average) and while improvements have been made in stroke care, the overall system of care is far from where it can be.

The idea is to extend the reach of care to underserved communities in Robeson County through Lumberton’s Southeastern Regional Medical Center (SRMC). This is made possible by an integrated knowledge, team, and service model between SRMC and the North Carolina Neurosciences Hospital at UNC (NSH-UNC):

1. Partner with the existing stroke services at the North Carolina Neurosciences Hospital at the University of North Carolina (NSH-UNC).
2. Implement a new stroke patient segmentation system to better match care needs with therapy options
3. Extend the reach of care to underserved communities in Robeson County through Lumberton’s Southeastern Regional Medical Center (SRMC).
4. Apply our System Design know-how to redesign and integrate a new comprehensive delivery system to better serve patient outcomes at lower costs.

Our approach is unique in that it is based on:
1. Triaging stroke patients along an integrated, full care cycle
2. Segmenting patients by imaging-based acuity to match them with most effective care
3. A hub and spoke delivery model to extend care to rural, underserved communities

We believe we have the right strategic insights, stakeholder buy-in, decision making support, and team partnership to implement a successful and robust system.

If you are interested in learning more, please contact us at:

Marco Steinberg
Director of Strategic Design
SITRA, the Finnish Innovation Fund