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.
Bradley
Elizabeth H
EH
Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8088, USA.
Curry
Leslie A
LA
Webster
Tashonna R
TR
Mattera
Jennifer A
JA
Roumanis
Sarah A
SA
Radford
Martha J
MJ
McNamara
Robert L
RL
Barton
Barbara A
BA
Berg
David N
DN
Krumholz
Harlan M
HM
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