Published online before print February 20, 2006, doi: 10.1161/CIRCULATIONAHA.105.590133
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(Circulation. 2006;113:1079-1085.)
© 2006 American Heart Association, Inc.
Health Services and Outcomes Research |
Achieving Rapid Door-To-Balloon Times
How Top Hospitals Improve Complex Clinical Systems
From the Division of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (E.H.B., T.R.W., H.M.K.); Department of Medicine, University of Connecticut School of Medicine, Farmington (L.A.C.); Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Conn (J.A.M., S.A.R., B.A.B., H.M.K.); Cardiology Division, Department of Medicine, New York University School of Medicine, New York (M.J.R.); Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Conn (R.L.M., H.M.K.); Department of Psychiatry, Yale University School of Medicine, New Haven, Conn (D.N.B.); and Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Conn (E.H.B., H.M.K.).
Correspondence to Dr Harlan M. Krumholz, Yale University School of Medicine 333 Cedar St, PO Box 208088, New Haven, CT 06520-8088. E-mail harlan.krumholz{at}yale.edu
Received September 23, 2005; revision received November 28, 2005; accepted November 30, 2005.
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.
Methods and 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 
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.
Key Words: health services research • myocardial infarction • quality
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