IT’S MONDAYNIGHT, 25 March 2024, and Cecília Braga dos Santos is giving the performance of her life. A packed auditorium claps along as the 79-year-old stroke survivor sings “Rosa Branca”, a Brazilian song about suffering, love and life.
Donna Cecília had a stroke while taking singing lessons. She was rushed to the only hospital in her city where doctors gave her a second chance at life. Tonight she has the chance to thank them by sharing her gift on the stage.
Next to her behind a raft of balloons and watching her sing with a smile on his face, is Dr Diógenes Guimarães Zãn, for whom this occasion represents the pinnacle of his academic and professional life.
Tonight, he is happier than he has ever been, thanks to the achievement of “an apparently impossible title”.
“This title was not granted to city with a large and resourceful university,” he says in an attempt to quantify its significance. “This title was granted to a small town where the only hospital is a municipal hospital without great resources that through the organization of care processes and engagement of people has managed to achieve a title of giants.”
The small city with the title of giants is Sapucaia do Sul, located 30 km north of Porto Alegre in southern Brazil, where Dr Diógenes leads the award-winning stroke team at Getúlio Vargas Municipal Hospital. It was largely thanks to his enthusiasm for changing stroke care in his city that Angels team leader Kamila Fachola chose Sapucaia do Sul to pilot a new strategy for stroke care transformation.
She had already converted Ribeirão Preto, a medium-sized city located in São Paulo state that became the first in the world to earn the status of Angels City. To achieve this designation, a city has to meet specific targets for public awareness education, emergency transport and acute care for stroke. With Getúlio Vargas Municipal Hospital having already won a WSO Angels Award, Sapucaia do Sul was one third of the way there. They would be carried across the finish line by collective goodwill and social mobilisation, local government support, a first-rate EMS, and a neurologist with a passion for process management and an understanding of Newtonian physics.
‘Newton was right’
Diógenes Guimarães Zãn grew up in a humble household with a solid work ethic. As a book-loving teenager he worked at a car wash, an experience that equipped him with the ability to deal with all kinds of people and sparked his appetite for a job well done.
Medicine was “the priesthood he chose” – committing to a lifetime of service for the benefit of patients. After six years studying medicine, three years of neurology, one year of vascular neurology, two years of interventional neuroradiology and two more years to obtain a master’s degree, he is not only his family’s first doctor. He is a medical professor at the University of Vale do Rio dos Sinos and neurologist and stroke specialist at Getúlio Vargas Municipal Hospital where he became coordinator of the stroke pathway in May 2021.
Between 2018 and 2020, intra-hospital mortality from stroke at this hospital had peaked at rates above 15 percent. By the end of 2023 it was down to 6,2 percent, the result of a process of training and process optimisation during which Dr Diógenes learnt that the greatest adversary of change was the one described by Newton’s law of inertia.
It’s the stubborn power of “it has always been this way”, he says. “Isaac Newton was right when he stated that the tendency of any object is to maintain its movement or to remain at rest. Modifying hospital processes, and convincing and encouraging people are very difficult stages of any positive change.”
Working with Angels to reorganize an entire city’s healthcare network expanded the priesthood considerably, but Dr Diógenes was not alone. Among those who embraced the project was Leticia Santomé, local head of the emergency service SAMU who during 10 years of emergency nursing encountered many stroke patients who “marked her hard”.
For Sapucaia do Sul to become an Angels City, SAMU had to win gold in the EMS Angels Awards and the first problem they had to confront was that they did not know how good they were.
“I was concerned about our data,” Leticia says. “We weren’t keeping accurate records of our cases and our team needed more knowledge about the fundamental role that prehospital care has in the outcomes for stroke patients.
“We held a team meeting where we outlined our new response time goals, more accurate indicators and the information that couldn’t be missed at the time of care. It took a month to finetune the details and to standardize the service. Training was provided by Dr Diógenes who also promoted the integration of the whole process of patient care and facilitated the relationship between institutions.
“After one month, a review of the data and process confirmed that care for patients affected by stroke had become faster and more effective.”
By the end of 2023 SAMU Sapucaia do Sul knew how good they were, only do discover that they were even better. After submitting their data to be considered for an EMS Angels Awards they learnt that they had overshot their target, joining their colleagues in Ribeirão Preto as the only EMS companies in Brazil to meet the criteria for a diamond award.
A night of giants
Everyone who heard Cecília Braga sing on 25 March had helped turn Sapucaia do Sul into an Angels City – including those invested with the power to change the rules whose support is indispensible to the Angels Cities strategy.
The mayor, Volmir Rodrigues, made a speech in which he dedicated the award to the population. The municipal secretary of health, Flávia Motta, observed that people from different disciplines working towards a single goal had enabled the city to save more lives. Djoidy Felipin who heads the secretariat of health commended the city’s teachers and students for “coming together in favour of life”. Implementation of the schools-based stroke education programme, FAST Heroes, was now mandatory for third-graders in the municipal network and 200 teachers had already been trained to familiarise around 4,000 students with the signs of stroke and the importance of calling 192.
They were witnessing another law of motion – the power that is generated when everyone changes direction and accelerates together towards a common goal. To produce this kind of energy – the kind that makes change contagious – Dr Diógenes leveraged his understanding of business process management (BPM), a discipline about which he is passionate.
Getúlio Vargas Municipal Hospital received no additional resources for improving its stroke care, he says. “BPM made a difference because it involves saving resources by optimizing processes that involve a particular purpose. Processes and steps that are not as useful or that are more time-consuming have been replaced by ones that are simplified, faster, assertive, and less costly.”
The application of BPM to organizing the stroke pathway is the topic of Dr Diógenes’s PhD thesis, which is being supervised by Prof Sheila Martins, past president of the WSO and founder and president of the Brazilian Stroke Network. Prof Martins also supervised his master’s thesis, and her presence in the auditorium on the happiest night of Dr Diógenes’s life was of great significance.
It elicits yet another Newtonian reference: “If I have seen any further than others, it is by standing upon the shoulders of giants.”
