Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST). Measuring four common patient harms in diverse care settings with the goal of supporting local improvement, the programme explicitly eschews a role for blame. The study design was ethnographic. We conducted 115 hours of observation across 19 care organisations and conducted 126 interviews with frontline staff, senior national leaders, experts in the four harms, and the NHS-ST programme leadership and development team. We also collected and analysed relevant documents. The programme theory of the NHS-ST was based in a logic of measurement for improvement: the designers of the programme sought to avoid the appropriation of the data for any purpose other than supporting improvement. However, organisational participants - both at frontline and senior levels - were concerned that the NHS-ST functioned latently as a blame allocation device. These perceptions were influenced, first, by field-level logics of accountability and managerialism and, second, by specific features of the programme, including public reporting, financial incentives, and ambiguities about definitions that amplified the concerns. In consequence, organisational participants, while they identified some merits of the programme, tended to identify and categorise it as another example of performance management, rich in potential for blame. These findings indicate that the search to optimise the benefits of measurement by controlling the risks of blame remains challenging. They further suggest that a well-intentioned programme theory, while necessary, may not be sufficient for achieving goals for improvement in healthcare systems dominated by institutional logics that run counter to the programme theory.

Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England.

INTRODUCTION: Harm from catheter-associated urinary tract infections is a common, potentially avoidable, healthcare complication. Variation in catheter prevalence may exist and provide opportunity for reducing harm, yet to date is poorly understood. This study aimed to determine variation in the prevalence of urinary catheters between patient groups, settings, specialities and over time. METHODS: A prospective study (July 2012 to April 2016) of National Health Service (NHS) patients surveyed by healthcare professionals, following a standardised protocol to determine the presence of a urinary catheter and duration of use, on 1 day per month using the NHS Safety Thermometer. RESULTS: 1314 organisations (253 NHS trusts) and 9 266 284 patients were included. Overall, 12.9% of patients were catheterised, but utilisation varied. There was higher utilisation of catheters in males (15.7% vs 10.7% p<0.001) and younger people (18-70 year 14.0% vs >70 year 12.8% p<0.001), utilisation was highest in hospital settings (18.6% p<0.001), particularly in critical care (76.6% p<0.001). Most catheters had been in situ <28 days (72.9% p<0.001). No clinically significant changes were seen over time in any setting or specialty. CONCLUSION: Catheter prevalence in patients receiving NHS-funded care varies according to gender, age, setting and specialty, being most prevalent in males, younger people, hospitals and critical care. Utilisation has changed only marginally over 46 months, and further guidance is indicated to provide clarity for clinicians on the insertion and removal of catheters to supplement the existing guidance on care.

Learning from the design, development and implementation of the Medication Safety Thermometer.

QUALITY ISSUE: Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time. INITIAL ASSESSMENT: A need for a prospective medication safety measurement tool was identified. CHOICE OF SOLUTION: The aim was to develop a tool to allow measurement and aid improvement of medication safety over time. The methodology used for the National Health Service (NHS) Safety Thermometer was identified as an approach. The resulting tool was named the 'Medication Safety Thermometer'. IMPLEMENTATION: The development of the Medication Safety Thermometer was facilitated by a multidisciplinary steering group using a Plan, Do, Study, Act (PDSA) method. Alpha and beta testing occurred over a period of 9 months. The tool was officially launched in October 2013 and continued to be improved until May 2016 using ongoing user feedback. EVALUATION: Feedback was gained through paper and online forms, and was discussed at regular steering group meetings. This resulted in 16 versions of the tool. The tool is now used nationally, with over 230 000 patients surveyed in over 100 NHS organizations. Data from these organizations are openly accessible on a dedicated website. LESSONS LEARNED: Measuring harm from medication errors is complex and requires steps to measure individual errors, triggers of harm and actual harm. PDSA methodology can be effectively used to develop measurement systems. Measurement at the point of care is beneficial and a multidisciplinary approach is vital.

Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach.

OBJECTIVES: We aimed to evaluate whether a large-scale two-phase quality improvement programme achieved its aims and to characterise the influences on achievement. SETTING: National Health Service (NHS) in England. PARTICIPANTS: NHS staff. INTERVENTIONS: The programme sought to (1) develop a shared national, regional and locally aligned safety focus for 4 high-cost, high volume harms; (2) establish a new measurement system based on a composite measure of 'harm-free' care and (3) deliver improved outcomes. Phase I involved a quality improvement collaborative intended to involve 100 organisations; phase II used financial incentives for data collection. MEASURES: Multimethod evaluation of the programme. In phase I, analysis of regional plans and of rates of data submission and clinical outcomes reported to the programme. A concurrent process evaluation was conducted of phase I, but only data on submission rates and clinical outcomes were available for phase II. RESULTS: A context of extreme policy-related structural turbulence impacted strongly on phase I. Most regions' plans did not demonstrate full alignment with the national programme; most fell short of recruitment targets and attrition in attendance at the collaborative meetings occurred over time. Though collaborative participants saw the principles underlying the programme as attractive, useful and innovative, they often struggled to convert enthusiasm into change. Developing the measurement system was arduous, yet continued to be met by controversy. Data submission rates remained patchy throughout phase I but improved in reach and consistency in phase II in response to financial incentives. Some evidence of improvement in clinical outcomes over time could be detected but was hard to interpret owing to variability in the denominators. CONCLUSIONS: These findings offer important lessons for large-scale improvement programmes, particularly when they seek to develop novel concepts and measures. External contexts may exert far-reaching influence. The challenges of developing measurement systems should not be underestimated.

Target CLAB Zero: A national improvement collaborative to reduce central line-associated bacteraemia in New Zealand intensive care units.

AIM: Central line-associated bacteraemia (CLAB) is a preventable cause of patient morbidity and mortality in intensive care units. Target CLAB Zero was a national campaign that ran from October 2011 to March 2013 across all New Zealand ICUs (intensive care units). The campaign aimed to reduce the national CLAB rate to less than one incident per 1,000 line days and to establish a national measurement system for CLAB. METHOD: We used Institute for Healthcare Improvement (IHI) Breakthrough Series methodology to structure the campaign. IHI bundles of care for catheter insertion and maintenance were implemented across 25 New Zealand ICUs. We collected monthly data on line days, CLAB infections and compliance with the bundles. Data were analysed using run charts. RESULTS: The rate of CLAB per 1,000 line days fell from 3.32 at baseline to an average of 0.28 between April 2012 and March 2013. In the final 3-month period, January to March 2013, average insertion bundle compliance was 80% and average maintenance bundle compliance was 75%. All ICUs participated in the collaborative. Over 90% of those invited attended all three national learning sessions and bi-monthly regional learning sessions. CONCLUSION: National collaboratives can effect improvement and shared learning in New Zealand. International evidence combined with New Zealand experience, a supportive methodology, partnership, clinical respect and an effective communication plan were keys to successful engagement.

Learning from the design and development of the NHS Safety Thermometer.

QUALITY ISSUE: Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available. INITIAL ASSESSMENT: We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally. CHOICE OF SOLUTION: We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients. IMPLEMENTATION: The NHS ST survey instrument was developed in a learning collaborative involving 161 organizations (e.g. hospitals and other delivery organizations) using a Plan, Do, Study, Act method. EVALUATION: Testing of operational definitions, technical capability and use were conducted and feedback systems were established by site coordinators in each participating organization. During the 17-month pilot, site coordinators reported a total of 73,651 patient entries. LESSONS LEARNED: It is feasible to obtain national data through standardized reporting by site coordinators at the point of care. Some caution is required in interpreting data and work is required locally to ensure data collection systems are robust and data collectors were trained. Sampling is an important strategy to optimize efficiency and reduce the burden of measurement.

Did a quality improvement collaborative make stroke care better? A cluster randomized trial.

BACKGROUND: Stroke can result in death and long-term disability. Fast and high-quality care can reduce the impact of stroke, but UK national audit data has demonstrated variability in compliance with recommended processes of care. Though quality improvement collaboratives (QICs) are widely used, whether a QIC could improve reliability of stroke care was unknown. METHODS: Twenty-four NHS hospitals in the Northwest of England were randomly allocated to participate either in Stroke 90:10, a QIC based on the Breakthrough Series (BTS) model, or to a control group giving normal care. The QIC focused on nine processes of quality care for stroke already used in the national stroke audit. The nine processes were grouped into two distinct care bundles: one relating to early hours care and one relating to rehabilitation following stroke. Using an interrupted time series design and difference-in-difference analysis, we aimed to determine whether hospitals participating in the QIC improved more than the control group on bundle compliance. RESULTS: Data were available from nine interventions (3,533 patients) and nine control hospitals (3,059 patients). Hospitals in the QIC showed a modest improvement from baseline in the odds of average compliance equivalent to a relative improvement of 10.9% (95% CI 1.3%, 20.6%) in the Early Hours Bundle and 11.2% (95% CI 1.4%, 21.5%) in the Rehabilitation Bundle. Secondary analysis suggested that some specific processes were more sensitive to an intervention effect. CONCLUSIONS: Some aspects of stroke care improved during the QIC, but the effects of the QIC were modest and further improvement is needed. The extent to which a BTS QIC can improve quality of stroke care remains uncertain. Some aspects of care may respond better to collaboratives than others. TRIAL REGISTRATION: ISRCTN13893902.

How collaborative are quality improvement collaboratives: a qualitative study in stroke care.

BACKGROUND: Quality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration. This literature has been relatively neglected in evaluations of QICs, even though they are founded on principles of co-operation and sharing. METHODS: We interviewed 32 professionals in hospitals that participated in Stroke 90:10, conducted a focus group with the QIC faculty team, and reviewed purposively sampled documents including reports and newsletters. Analysis was based on a modified form of Framework Analysis, combining sensitizing constructs derived from the literature and new, empirically derived thematic categories. RESULTS: Improvements in stroke care were attributed to QIC participation by many professionals. They described how the QIC fostered a sense of community and increased attention to stroke care within their organizations. However, participants' experiences of the QIC varied. Starting positions were different; some organizations were achieving higher levels of performance than others before the QIC began, and some had more pre-existing experience of quality improvement methods. Some participants had more to learn, others more to teach. Some evidence of free-riding was found. Benchmarking improvement was variously experienced as friendly rivalry or as time-consuming and stressful. Participants' competitive desire to demonstrate success sometimes conflicted with collaborative aims; some experienced competing organizational pressures or saw the QIC as duplication of effort. Experiences of inter-organizational collaboration were influenced by variations in intra-organizational support. CONCLUSIONS: Collaboration is not the only mode of behavior likely to occur within a QIC. Our study revealed a mixed picture of collaboration, free-riding and competition. QICs should learn from work on the challenges of collective action; set realistic goals; account for context; ensure sufficient time and resources are made available; and carefully manage the collaborative to mitigate the risks of collaborative inertia and unhelpful competitive or anti-cooperative behaviors. Individual organizations should assess the costs and benefits of collaboration as a means of attaining quality improvement.

There is another way: empowering frontline staff caring for acutely unwell adults.

QUALITY PROBLEM OR ISSUE: It is estimated that only 17% of patients survive an in-hospital cardiac arrest. Medical evidence indicates that many patients show signs of deterioration during the 24 h period prior to their cardiac arrest. INITIAL ASSESSMENT: At Salford Royal NHS Foundation Trust (SRFT) 135 patients (outside critical care areas) suffered a cardiac arrest between March 2007 and April 2008. CHOICE OF SOLUTION: Quality improvement method-The breakthrough series (BTS) collaborative approach, change package-reliable manual vital signs, nurse-led response to the deteriorating patient, code red, structured ward round, ceilings of care, nurse-led do not attempt cardiopulmonary resuscitation (DNA-CPR) protocol and allocated roles. IMPLEMENTATION: The project was delivered over two phases with a total of 23 wards (12 wards in Phase One and 11 wards in Phase Two). Frontline teams worked to develop changes with the aim of reducing cardiac arrests by 50%. EVALUATION: The primary outcome measure was the number of cardiac arrests per 1000 admissions outside of critical care areas. Process and balancing measures were also used to evaluate the impact of the intervention. LESSONS LEARNED: The results showed a positive relationship between the change package and a reduction of 41% in cardiac arrests outside of critical care areas from the baseline period (April 2007-March 2008) to December 2012. The BTS model has the potential to reduce cardiac arrests without the need for initial large-scale financial investment.

What is the NHS Safety Thermometer?

The English National Health Service (NHS) announced a new programme to incentivize use of the NHS Safety Thermometer (NHS ST) in the NHS Operating Framework for 2012/13. For the first time, the NHS is using the Commissioning for Quality and Innovation (CQUIN) scheme, a contract lever, to incentivize ALL providers of NHS care to measure four common complications (harms) using the NHS ST in a proactive way on one day per month. This national CQUIN scheme provides financial reward for the collection of baseline data with a view to incentivizing the achievement of improvement goals in later years. In this paper, we describe the rationale for this large-scale data collection, the purpose of the instrument and its potential contribution to our current understanding of patient safety. It is not a comprehensive description of the method or preliminary data. This will be published separately. The focus of the NHS ST on pressure ulcers, falls, catheters and urine infection and venous thromboembolism is broadly applicable to patients across all healthcare settings, but is specifically pertinent to older people who, experiencing more healthcare intervention, are at risk of not one but multiple harms. In this paper, we also describe an innovative patient-level composite measure of the absence of harm from the four identified, termed as "harmfreecare" which is unique to the NHS ST and is under development to raise standards for patient safety.

The imperative to improve safety in NHS healthcare organisations.

Since the publication of a report on learning from adverse events in the NHS a decade ago, healthcare organisations have signed up to programmes to improve safety, investing staff, time and other resources in systems for reporting events and developing processes to ensure better outcomes. This article highlights initiatives that build on this work.

Reducing Clostridium difficile infection in acute care by using an improvement collaborative.

PROBLEM: In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England. DESIGN: Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group). SETTING: University teaching hospital with 850 acute beds. KEY MEASURES FOR IMPROVEMENT: Number of cases of C difficile infection per 1000 occupied bed days. STRATEGIES FOR CHANGE: In February 2007, a newly formed antimicrobial team led the implementation of revised guidelines in all wards and departments. From March to December 2007, five wards participated in an improvement collaborative. Since December 2007, the changes from the collaborative have been collated and implemented throughout the organisation. EFFECTS OF CHANGE: At baseline the non-collaborative wards had 1.15 (95% CI 1.03 to 1.29) cases per 1000 occupied bed days. In August 2007 cases reduced 56% from baseline (0.51, 0.44 to 0.60), which has been maintained since that time. In the collaborative wards, there were 2.60 (2.11 to 3.17) cases per 1000 occupied bed days at baseline. A shift occurred in April 2007 representing a reduction of 73% (0.69, 0.50 to 0.91) from baseline, which has been maintained. LESSONS LEARNT: Careful use of antimicrobial drugs is important in reducing the number of cases of C difficile infection. A collaborative learning model can enable teams to test and implement changes that can accelerate, amplify, and sustain control of C difficile.

Spatiotemporal visualizations for the measurement of oropharyngeal transit time from videofluoroscopy.

Videofluoroscopy remains one of the mainstay methods for clinical swallowing assessment, yet its interpretation is both complex and subjective. This, in part, reflects the difficulties associated with estimation of bolus transit time through the oral and pharyngeal regions by visual inspection, and problems with consistent repeatability. This paper introduces a software-only framework that automatically determines the time taken for the bolus to cross 1-D anatomical landmarks representing the oral and pharyngeal region boundaries ( Fig. 1). The user-steered delineation algorithm live-wire and straight-line annotators are used to demarcate the landmark on a frame prior to the swallow action. The rate of change of intensity of the pixels in each landmark is used as the detection feature for bolus presence that can be visualized on a spatiotemporal plot. Artifacts introduced by head and neck movement are removed by updating the landmark coordinates using affine parameters optimized by a genetic-algorithm-based registration method. Heuristics are applied to the spatiotemporal plot to identify the frames during which the bolus passes the landmark. Correlation coefficients between three observers visually inspecting twenty-four 5-mL single swallow clips did not exceed 0.42. Yet the same measurements taken using this framework on the same clips had correlation coefficients exceeding 0.87.

Predicting aspiration after hemispheric stroke from timing measures of oropharyngeal bolus flow and laryngeal closure.

Deglutitive aspiration is common after stroke, affecting up to 50% of patients and predisposing them to pneumonia, yet it is virtually impossible to predict those patients at greatest risk. The aim of this study was to develop a robust predictive model for aspiration after stroke. Swallowing was assessed by digital videofluoroscopy (VF) in 90 patients following hemispheric stroke. Lesion characteristics were determined by computerized tomography (CT) brain scan using the Alberta Stroke Programme Early CT Score (ASPECTS). Aspiration severity was measured using a validated penetration-aspiration scale. The probability of aspiration was then determined from measures of swallowing pathophysiology and lesion location by discriminant analysis. Aspiration was observed in 47 (52%) patients, yet despite disrupted swallowing physiology, intrasubject aspiration scores were variable. The best discriminant model combined pharyngeal transit time, swallow response time, and laryngeal closure duration to predict 73.11% of those aspirating (sensitivity = 66.54, specificity = 80.22, p > 0.001). The addition of lesion location did not add anything further to the predictive model. We conclude that the pathophysiology of poststroke aspiration is multifactorial but in most cases can be predicted by three key swallowing measurements. These measurements, if translatable into clinical bedside evaluation, may assist with the development of novel measurement and intervention techniques to detect and treat poststroke aspiration.

Evaluation of a service development to implement the top three process indicators for quality stroke care.

RATIONALE, AIM AND OBJECTIVE: Stroke mortality remains unacceptably high with up to 30% of patients dying within 1 month. Early swallow screen and computerized tomography (CT) brain scan, facilitate delivery of aspirin, which together are recognized as the top three process indicators for quality stroke care. Evidence indicates that treatment with aspirin (300 mg) saves lives and should commence within 48 h of stroke onset. However, many hospitals find it difficult to meet this timescale. We aimed to evaluate whether reorganization of services could improve aspirin delivery following acute ischaemic stroke. METHOD: A retrospective audit was carried out to determine the time to swallow screen, CT scan and aspirin administration. A service review was conducted and the findings disseminated. A decision was made to reorganize services by enhancing the role of senior nursing staff to: (1) admit patients, (2) request CT brain scans, (3) screen for swallowing abnormality, and (4) prescribe the first dose of aspirin. A second audit was conducted to evaluate the impact of the new service. RESULTS: Before reorganization, 30% had swallowing screened and 38% had CT scans within 24 h. Thirty-one per cent received their first dose of aspirin within 48 h. After reorganization, 68% had their swallowing screened and 80% had a CT scan within 24 h. Ninety per cent of patients received their first dose of aspirin within 48 h. CONCLUSIONS: Modernizing service delivery by changing traditional roles can offer quality solutions ensuring that aspirin delivery is expedited by early swallow screen and CT scan. These initiatives could be used more widely to improve patient care and implement the top three process indicators for stroke.

Evaluating oral stimulation as a treatment for dysphagia after stroke.

Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke. Swallowing was assessed before and 60 min after 0.2-Hz electrical or sham stimulation in 16 stroke patients (12 male, mean age = 73 +/- 12 years). Swallowing measures included laryngeal closure (initiation and duration) and pharyngeal transit time, taken from digitally acquired videofluoroscopy. Aspiration severity was assessed using a validated penetration-aspiration scale. Preintervention, the initiation of laryngeal closure, was delayed in both groups, occurring 0.66 +/- 0.17 s after the bolus arrived at the hypopharynx. The larynx was closed for 0.79 +/- 0.07 s and pharyngeal transit time was 0.94 +/- 0.06 s. Baseline swallowing measures and aspiration severity were similar between groups (stimulation: 24.9 +/- 3.01; sham: 24.9 +/- 3.3, p = 0.2). Compared with baseline, no change was observed in the speed of laryngeal elevation, pharyngeal transit time, or aspiration severity within subjects or between groups for either active or sham stimulation. Our study found no evidence for functional change in swallow physiology after faucial pillar stimulation in dysphagic stroke. Therefore, with the parameters used in this study, oral stimulation does not offer an effective treatment for poststroke patients.

Awareness of dysphagia by patients following stroke predicts swallowing performance.

Patients' awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of "a swallowing problem" and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke. Patients were screened for dysphagia by clinical assessment, followed by a timed water swallow test to examine swallowing performance. Patient awareness of dysphagia and its significance were determined by detailed question-based assessment. Medical records were examined at three months. Dysphagia was identified in 27 patients, 16 of whom had poor awareness of their dysphagic symptoms. Dysphagic patients with poor awareness drank water more quickly (5 ml/s vs. <1 ml/s, p = 0.03) and took larger volumes per swallow (10 ml vs. 6 ml, p = 0.04) than patients with good awareness. By comparison, neither patients with good awareness or poor awareness perceived they had a swallowing problem. Patients with poor awareness experienced numerically more complications at three months. Stroke patients with good awareness of the clinical indicators of dysphagia modify the way they drink by taking smaller volumes per swallow and drink more slowly than those with poor awareness. Dysphagic stroke patients, regardless of good or poor awareness of the clinical indicators of dysphagia, rarely perceive they have a swallowing problem. These findings may have implications for longer-term outcome, patient compliance, and treatment of dysphagia after stroke.

Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia.

We investigated the effects of water swallowing, pharyngeal stimulation, and oropharyngeal anesthesia on corticobulbar and craniobulbar projections to human swallowing musculature. Changes in pathway excitability were measured via electromyography from swallowed intraluminal pharyngeal and esophageal electrodes to motor cerebral and trigeminal nerve magnetic stimulation. After both water swallowing and pharyngeal stimulation, pharyngoesophageal corticobulbar excitability increased (swallowing: pharynx = 59 +/- 12%, P < 0.001; esophagus = 45 +/- 20%, P < 0.05; pharyngeal stimulation: pharynx = 76 +/- 19%, P < 0.001; esophagus = 45 +/- 23%, P = 0.05), being early with swallowing but late with stimulation. By comparison, craniobulbar excitability increased early after swallowing but remained unaffected by pharyngeal stimulation. After anesthesia, both corticobulbar (pharynx =-24 +/- 10%, P < 0.05; esophagus = -28 +/- 7%, P < 0.01) and craniobulbar excitability showed a late decrease. Thus swallowing induces transient early facilitation of corticobulbar and craniobulbar projections, whereas electrical stimulation promotes delayed facilitation mainly in cortex. With removal of input, both corticobulbar and craniobulbar projections show delayed inhibition, implying a reduction in motoneuron and/or cortical activity.

Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury.

Changes in somatosensory input can remodel human cortical motor organization, yet the input characteristics that promote reorganization and their functional significance have not been explored. Here we show with transcranial magnetic stimulation that sensory-driven reorganization of human motor cortex is highly dependent upon the frequency, intensity, and duration of stimulus applied. Those patterns of input associated with enhanced excitability (5 Hz, 75% maximal tolerated intensity for 10 min) induce stronger cortical activation to fMRI. When applied to acutely dysphagic stroke patients, swallowing corticobulbar excitability is increased mainly in the undamaged hemisphere, being strongly correlated with an improvement in swallowing function. Thus, input to the human adult brain can be programmed to promote beneficial changes in neuroplasticity and function after cerebral injury.