In 2009 the Stroke Quality Enhancement Research Initiative (QUERI) group, led by Drs. Linda Williams and Dawn Bravata, conducted a study of the quality of inpatient stroke care across all VA hospitals. The study measured 10 Joint Commission and 4 VA-specific quality indicators at more than 130 VA hospitals. A key finding of this research was that early stroke processes of care, compared to care later in the hospitalization or at discharge, had the most room for improvement. The Stroke QUERI also developed a web-based toolkit of stroke quality improvement tools; receiving more than 12,000 hits in Fiscal Year 2010. As a result of this research, Stroke QUERI investigators worked closely with the VA Office of Specialty Care, including Emergency Medicine, Neurology, and Nursing, to develop a VA Acute Ischemic Stroke Directive. This Directive was approved and signed by the Under-Secretary for Health in November 2011. The Directive requires all VA hospitals to identify their ability to provide thrombolysis for acute stroke treatment, to organize stroke care according to best practices, and to begin monthly measurement and reporting of three inpatient stroke quality indicators. Stroke QUERI investigators also led the roll-out of this Directive, providing Live Meeting acute stroke training sessions for all VA hospitals nationwide. Also as a result of the 2009 evidence-practice gap study, Dr. Williams is leading a 12-site randomized trial of quality improvement training plus performance data feedback versus data feedback alone, to improve two acute stroke quality indicators. This project will evaluate the benefit of specific quality improvement training, and will investigate relationships between the local culture and context of care and subsequent care improvements at the 12 hospitals.