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Introduction: The rapid diagnosis of an acute (AIS) ischemic stroke and determination of tPA eligibility requires efficient clinical processes and care coordination. Several quality initiatives have focused on door to needle time (DNT) and tPA rates, but few studies have investigated the impact of specific clinical-process elements on improving these quality metrics.Hypothesis: There are specific elements of triage and diagnosis processes that are associated with reduced DNT and higher tPA rates.Methods: A 42-item survey assessing the implementation times of 21 interventions was distributed to facilities in a large hospital system; median quarterly DNT and tPA rates were extracted for 2015-2017 for all hospitals surveyed. We compared the average DNT and tPA rates before and after implementation of the intervention using t-tests and ANOVA. When before-after comparisons were not possible, we compared the average DNT and tPA between facilities that implemented and did not implement the intervention.Results: 83 (47%) hospitals completed the survey. We found that strong predictors of post-intervention reduction of DNT (p < 0.01) included (i) implementation of pre-hospital communications with EMS, (ii) employment of a full-time stroke coordinator, (iii) bypassing the ED to go directly to a CT scan and (iv) pre-mixing tPA prior to CT. Including a pharmacist and registrar when responding to stroke alerts had the strongest effect on tPA rate (p < 0.01). Weaker effects on tPA rates were seen for implementations of point of care testing for different laboratory values and prioritizing the processing of labs orders for strokes.Conclusions: This study identified several interventions with the strong effect on DNT and tPA rates, suggesting these interventions could be prioritized at stroke centers. Our results also suggest some commonly cited clinical processes are not associated with shorted DNT and increased tPA rates.