Background:
Stroke patients are often inactive outside of structured therapy sessions – an enduring
international challenge despite large scale organisational changes, national guidelines and
performance targets. We examined whether Experienced-based Co-design (EBCD) - an improvement methodology- could address inactivity in stroke units.

Aims:
To evaluate the feasibility and impact of patients, carers and staff co-designing and implementing improvements to increase supervised and independent therapeutic patient activity in stroke units and to compare use of full and accelerated EBCD cycles.

Methods:
Mixed-methods case comparison in four stroke units in England.

Results:
Interviews n=156 patients, staff and carers, ethnographic observations –n=365 hours, behavioural mapping n=68 patients, and self-report surveys n=182 patients pre and post implementation of EBCD improvement cycles. Three priority areas emerged 1) ‘Space’ (environment) 2) ‘Activity opportunities’ and 3) ‘Communication’. More than 40 improvements were co-designed and implemented to address these
priorities across participating units. Post-implementation interview and ethnographic observational
data confirmed use of new social spaces and increased activity opportunities. However, staff
interactions remained largely task-driven with limited focus on enabling patient activity. Behavioural
mapping indicated some increases in social, cognitive and physical activity post-implementation but
was variable across sites. Survey responses rates were low at 12-38% and inconclusive.

Conclusion
It was feasible to implement EBCD in stroke units. This resulted in multiple improvements in stroke unit environments and increased activity opportunities but minimal change in recorded activity levels. There was no discernible difference in experience or outcome between full and accelerated EBCD; this methodology could be used across hospital stroke units to assist staff and other stakeholders to co-design and implement improvement plans.