Several specific hospital strategies are associated with a significant reduction in the door-to-balloon time in the management of myocardial infarction with ST-segment elevation.

ANY STUDIES HAVE DEMonstrated different patterns of cardiovascular care by racial and ethnic groups, 1-4 but few have investigated the relative contributions of sociodemographic, economic, clinical, or health system factors to these differences. Understanding the sources of racial and ethnic differences in cardiovascular care is paramount to designing effective interventions to eliminate disparities, which has been designated as a national priority. 5-7 Therefore, studies are needed to examine the broad range of factors that might explain racial and ethnic differences in care. Acute reperfusion for patients presenting with ST-segment elevation myocardial infarction (STEMI) provides a good opportunity to examine the interplay of patient and health system features and racial and ethnic differences in cardiovascular care. Prompt reperfusion markedly improves survival for patients with STEMI 8-11 and is an indicator of quality of care used by the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations. Recent reports indicate that patients identified as African American/black or as nonwhite minority experience signifi-Author Affiliations are listed at the end of this article.

Translating research into clinical practice is challenging for staff across disciplines. Developing strategies to address common challenges identified in this study may facilitate the adoption of innovative programs within healthcare organizations.

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 (nϭ122) 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 Յ90 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.