Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems.
BACKGROUND
Fewer than half of patients with ST-elevation acute myocardial infarction (STEMI) are treated within guideline-recommended door-to-balloon times; however, little information is available about the approaches used by hospitals that have been successful in improving door-to-balloon times to meet guidelines. We sought to characterize experiences of hospitals with outstanding improvement in door-to-balloon time during 1999-2002.


RESULTS
We performed a qualitative study using in-depth interviews (n=122) with clinical and administrative staff at 11 hospitals that were participating with the National Registry of Myocardial Infarction and had median door-to-balloon times of < or =90 minutes during 2001-2002, representing substantial improvement since 1999. Data were organized with the use of NUD-IST 4 (Sage Publications Software) and were analyzed by the constant comparative method of qualitative data analysis. Eight themes characterized hospitals' experiences: commitment to an explicit goal to improve door-to-balloon time motivated by internal and external pressures; senior management support; innovative protocols; flexibility in refining standardized protocols; uncompromising individual clinical leaders; collaborative teams; data feedback to monitor progress and identify problems and successes; and an organizational culture that fostered resilience to challenges or setbacks in improvement efforts.


CONCLUSIONS
Several themes characterized the experiences of hospitals that had achieved notable improvements in their door-to-balloon times. By distilling the complex and diverse experiences of organizational change into its essential components, this study provides a foundation for future efforts to elevate clinical performance in the hospital setting.
Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8088, USA.
Elizabeth H
EH
Bradley
Leslie A
LA
Curry
Tashonna R
TR
Webster
Jennifer A
JA
Mattera
Sarah A
SA
Roumanis
Martha J
MJ
Radford
Robert L
RL
McNamara
Barbara A
BA
Barton
David N
DN
Berg
Harlan M
HM
Krumholz
D015906:Angioplasty, Balloon, Coronary / Q000592:standards*; D019983:Guideline Adherence; D006296:Health Services / Q000592:standards; D006761:Hospitals / Q000592:standards; D006801:Humans; D007407:Interviews as Topic; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy*; D011787:Quality of Health Care / Q000706:statistics & numerical data; D013997:Time Factors