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Background: Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies., Methods and Results: We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals' efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48-0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach α coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents., Conclusions: We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts., (© 2017 American Heart Association, Inc.)

Background: Hospitals across the United States are pursuing strategies to reduce avoidable readmissions but the evidence on how best to accomplish this goal is mixed, with no specific clinical practice shown to reduce readmissions consistently. Changes to hospital organizational practices, a key component of context, also may be critical to improving performance on readmissions, but this has not been studied., Objective: The aim of this study was to understand how high-performing hospitals improved risk-stratified readmission rates, and whether their changes to clinical practices and organizational practices differed from low-performing hospitals., Design: This was a qualitative study of 10 hospitals in which readmission rates had decreased (n=7) or increased (n=3)., Participants: A total of 82 hospital staff drawn from hospitals that had participated in the State Action on Avoidable Readmissions quality improvement initiative., Results: High-performing hospitals were distinguished by several organizational practices that facilitated readmissions reduction, that is, collective habits of action or interpretation shared by organization members. First, high-performing hospitals reported focused efforts to improve collaboration across hospital departments. Second, they helped postacute providers improve care by sharing the hospital's clinical and quality improvement expertise and data. Third, high performers enthusiastically engaged in trial and error learning to reduce readmissions. Fourth, they emphasized that readmissions represented bad outcomes for patients, de-emphasizing the role of financial penalties. Both high-performing and low-performing hospitals had implemented most clinical practice changes commonly recommended to reduce readmissions., Conclusions: Our findings highlight several organizational practices that hospitals may be able to use to enhance the effectiveness of their readmissions reduction efforts.

Background: Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR)., Objective: We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12-18 months in a national sample of hospitals., Design: We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010-May 2011, n = 599, 91.0% response rate) and 12-18 months later (November 2011-October 2012, n = 501, 83.6% response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals., Participants: The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives., Main Measures: We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression., Key Results: The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3%) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used., Conclusions: Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.

Background: Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL)., Methods: This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time., Conclusions: LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change.

This article examines the effect on quality improvement of two common but distinct approaches to organizational learning: importing best practices (an externally oriented approach rooted in learning by imitating others' best practices) and internal creative problem solving (an internally oriented approach rooted in learning by experimenting with self-generated solutions). We propose that independent and interaction effects of these approaches depend on where organizations are in their improvement journey - initial push or later phase. We examine this contingency in hospitals focused on improving treatment time for patients with heart attacks. Our results show that importing best practices helps hospitals achieve initial phase but not later phase improvement. Once hospitals enter the later phase of their efforts, however, significant improvement requires creative problem solving as well. Together, our results suggest that importing best practices delivers greater short-term improvement, but continued improvement depends on creative problem solving., (© The Author(s) 2014.)

Background: Survival rates after acute myocardial infarction (AMI) vary markedly across U.S. hospitals. Although substantial efforts have been made to improve hospital performance, we lack contemporary evidence about changes in hospital strategies and features of organizational culture that might contribute to reducing hospital AMI mortality rates. We sought to describe current use of several strategies and features of organizational culture linked to AMI mortality in a national sample of hospitals and examine changes in use between 2010 and 2013., Methods: We conducted a cross-sectional survey of 543 hospitals (70% response rate) in 2013, and longitudinal analysis of a subsample of 107 hospitals that had responded to a survey in 2010 (67% response rate)., Results: Between 2010 and 2013, the use of many strategies increased, but the use of only two strategies increased significantly: the percentage of hospitals providing regular training to Emergency Medical Service (EMS) providers about AMI care increased from 36% to 71% (P-value < 0.001) and the percentage of hospitals using computerized assisted physician order entry more than doubled (P-value < 0.001). Most, but not all, hospitals reported having environments conducive to communication, coordination and problem solving., Conclusions: We found few significant changes between 2010 and 2013 in hospital strategies or in key features of organizational culture that have been associated with lower AMI mortality rates. Findings highlight several opportunities to help close remaining performance gaps in AMI mortality among hospitals.

Background: Decentralization through the establishment of hospital governing boards has been touted as an effective way to improve the quality and efficiency of hospitals in low-income countries. Although several studies have examined the process of decentralization, few have quantitatively assessed the implementation of hospital governing boards and their impact on hospital performance. Therefore, we sought to describe the functioning of governing boards and to determine the association between governing board functioning and hospital performance., Methods: We conducted a cross-sectional study with governing board chairpersons to assess board (1) structure, (2) roles and responsibilities and (3) training and orientation practices. Using bivariate analysis and multivariable regression, we examined the association between governing board functioning and hospital performance. Hospital performance indicators: 1) percent of hospital management standards met, measured with the Ethiopian Hospital Reform Implementation Guidelines and 2) patient experience, measured with the Inpatient and Outpatient Assessment of Healthcare surveys., Results: A total of 92 boards responded to the survey (96% response rate). The average percentage of EHRIG standards met was 58.1% (standard deviation (SD) 21.7 percentage points), and the mean overall patient experience score was 7.2 (SD 2.2). Hospitals with greater hospital management standards met had governing boards that paid members, reviewed performance in several domains quarterly or more frequently, developed new revenue sources, determined services to be outsourced, reviewed patient complaints, and had members with knowledge in business and financial management (all P-values < 0.05). Hospitals with more positive patient experience had governing boards that developed new revenue sources, determined services to be outsourced, and reviewed patient complaints (all P-values < 0.05)., Conclusions: These cross-sectional data suggest that strengthening governing boards to perform essential responsibilities may result in improved hospital performance.

Background: Reducing hospital readmission rates is a national priority; however, evidence about hospital strategies that are associated with lower readmission rates is limited. We sought to identify hospital strategies that were associated with lower readmission rates for patients with heart failure., Methods and Results: Using data from a Web-based survey of hospitals participating in national quality initiatives to reduce readmission (n=599; 91% response rate) during 2010-2011, we constructed a multivariable linear regression model, weighted by hospital volume, to determine strategies independently associated with risk-standardized 30-day readmission rates (RSRRs) adjusted for hospital teaching status, geographic location, and number of staffed beds. Strategies that were associated with lower hospital RSRRs included the following: (1) partnering with community physicians or physician groups to reduce readmission (0.33% percentage point lower RSRRs; P=0.017), (2) partnering with local hospitals to reduce readmissions (0.34 percentage point; P=0.020), (3) having nurses responsible for medication reconciliation (0.18 percentage point; P=0.002), (4) arranging follow-up appointments before discharge (0.19 percentage point; P=0.037), (5) having a process in place to send all discharge paper or electronic summaries directly to the patient's primary physician (0.21 percentage point; P=0.004), and (6) assigning staff to follow up on test results that return after the patient is discharged (0.26 percentage point; P=0.049). Although statistically significant, the magnitude of the effects was modest with individual strategies associated with less than half a percentage point reduction in RSRRs; however, hospitals that implemented more strategies had significantly lower RSRRs (reduction of 0.34 percentage point for each additional strategy)., Conclusions: Several strategies were associated with lower hospital RSRRs for patients with heart failure.

Importance: The Centers for Medicare & Medicaid Services publicly reports hospital 30-day, all-cause, risk-standardized mortality rates (RSMRs) and 30-day, all-cause, risk-standardized readmission rates (RSRRs) for acute myocardial infarction, heart failure, and pneumonia. The evaluation of hospital performance as measured by RSMRs and RSRRs has not been well characterized., Objective: To determine the relationship between hospital RSMRs and RSRRs overall and within subgroups defined by hospital characteristics., Design, Setting, and Participants: We studied Medicare fee-for-service beneficiaries discharged with acute myocardial infarction, heart failure, or pneumonia between July 1, 2005, and June 30, 2008 (4506 hospitals for acute myocardial infarction, 4767 hospitals for heart failure, and 4811 hospitals for pneumonia). We quantified the correlation between hospital RSMRs and RSRRs using weighted linear correlation; evaluated correlations in groups defined by hospital characteristics; and determined the proportion of hospitals with better and worse performance on both measures., Main Outcome Measures: Hospital 30-day RSMRs and RSRRs., Results: Mean RSMRs and RSRRs, respectively, were 16.60% and 19.94% for acute myocardial infarction, 11.17% and 24.56% for heart failure, and 11.64% and 18.22% for pneumonia. The correlations between RSMRs and RSRRs were 0.03 (95% CI, -0.002 to 0.06) for acute myocardial infarction, -0.17 (95% CI, -0.20 to -0.14) for heart failure, and 0.002 (95% CI, -0.03 to 0.03) for pneumonia. The results were similar for subgroups defined by hospital characteristics. Although there was a significant negative linear relationship between RSMRs and RSRRs for heart failure, the shared variance between them was only 2.9% (r2 = 0.029), with the correlation most prominent for hospitals with RSMR <11%., Conclusion and Relevance: Risk-standardized mortality rates and readmission rates were not associated for patients admitted with an acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure.

Background: Despite recent improvements in survival after acute myocardial infarction (AMI), U.S. hospitals vary 2-fold in their 30-day risk-standardized mortality rates (RSMRs). Nevertheless, information is limited on hospital-level factors that may be associated with RSMRs., Objective: To identify hospital strategies that were associated with lower RSMRs., Design: Cross-sectional survey of 537 hospitals (91% response rate) and weighted multivariate regression by using data from the Centers for Medicare & Medicaid Services to determine the associations between hospital strategies and hospital RSMRs., Setting: Acute care hospitals with an annualized AMI volume of at least 25 patients., Participants: Patients hospitalized with AMI between 1 January 2008 and 31 December 2009., Measurements: Hospital performance improvement strategies, characteristics, and 30-day RSMRs., Results: In multivariate analysis, several hospital strategies were significantly associated with lower RSMRs and in aggregate were associated with clinically important differences in RSMRs. These strategies included holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital (RSMR lower by 0.70 percentage points), having cardiologists always on site (lower by 0.54 percentage points), fostering an organizational environment in which clinicians are encouraged to solve problems creatively (lower by 0.84 percentage points), not cross-training nurses from intensive care units for the cardiac catheterization laboratory (lower by 0.44 percentage points), and having physician and nurse champions rather than nurse champions alone (lower by 0.88 percentage points). Fewer than 10% of hospitals reported using at least 4 of these 5 strategies., Limitation: The cross-sectional design demonstrates statistical associations but cannot establish causal relationships., Conclusion: Several strategies, which are currently implemented by relatively few hospitals, are associated with significantly lower 30-day RSMRs for patients with AMI., Primary Funding Source: The Agency for Healthcare Research and Quality, the United Health Foundation, and the Commonwealth Fund.

Background: Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams., Objective: We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times., Design: Qualitative study., Participants: Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times., Measurements: Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals., Results: Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively., Conclusions: The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff., (Copyright © 2011 Society of Hospital Medicine.)

Objective: The aim of this study was to develop and to assess the validity and reliability of two brief questionnaires for assessing patient experiences with hospital and outpatient care in a low-income setting., Design: Using literature review and data from focus groups (n = 14), we developed questionnaires to assess patient experiences with inpatient (I-PAHC) and with outpatient (O-PAHC) care in a low-income setting. Questionnaires were administered in person by trained interviewers. Construct validity was assessed with factor analysis; convergent validity was assessed by correlating summary scores for each scale with overall patient evaluations, and reliability was assessed with Cronbach's alpha coefficients., Setting: Eight health facilities in Ethiopia., Participants: Patients >18 years old who had a hospital stay >1 day (n = 230), and patients who received outpatient care (n = 486)., Main Outcome Measures: Patient evaluations of health care experiences., Results: The factor analysis revealed 12 items that loaded on five factors for the I-PAHC questionnaire. The O-PAHC showed similar results with 13 items that loaded on four factors. Summary scores for nearly all factors were significantly associated (P-value < 0.05) with the patient's overall evaluation score. The measure of reliability, Cronbach's alpha coefficients, showed good to excellent internal consistency for all scales., Conclusions: The I-PAHC on O-PAHC questionnaires can be useful in assessing patients' evaluations of care delivery in low-income settings. The questionnaires are brief and can be integrated into health systems strengthening efforts with the support of leadership at the health facility and the country levels.

Background: Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation., Objective: To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates., Design: Qualitative study that used site visits and in-depth interviews., Setting: Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics., Participants: 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals., Measurements: Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method., Results: Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals., Limitation: The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed., Conclusion: High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI., Primary Funding Source: Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

Objective: To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements., Data Sources: In-depth interviews, hospital surveys, and Health Quality Alliance data., Study Design: We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N = 99) at hospitals reporting strong influence (n = 6) as well as hospitals reporting limited influence (n = 6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data., Data Collection Methods: In-depth, open-ended interviews; hospital survey., Principal Findings: Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes., Conclusions: The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals., (© Health Research and Educational Trust.)

Hospitals vary by twofold in their hospital-specific 30-day risk-stratified mortality rates (RSMRs) for Medicare beneficiaries with acute myocardial infarction (AMI). However, we lack a comprehensive investigation of hospital characteristics associated with 30-day RSMRs and the degree to which the variation in 30-day RSMRs is accounted for by these characteristics, including the socioeconomic status (SES) profile of hospital patient populations. We conducted a cross-sectional national study of hospitals with ≥15 AMI discharges from July 1, 2005 to June 20, 2008. We estimated a multivariable weighted regression using Medicare claims data for hospital-specific 30-day RSMRs, American Hospital Association Survey of Hospitals for hospital characteristics, and the United States Census data reported by Neilsen Claritas, Inc., for zip-code level estimates of SES status. Analysis included 2,908 hospitals with 513,202 AMI discharges. Mean hospital 30-day RSMR was 16.5% (SD 1.7 percentage points). Our multivariable model explained 17.1% of the variation in hospital-specific 30-day RSMRs. Teaching status, number of hospital beds, AMI volume, cardiac facilities available, urban/rural location, geographic region, ownership type, and SES profile of patients were significantly (p < 0.05) associated with 30-day RSMRs. In conclusion, substantial variation in hospital outcomes for patients with AMI remains unexplained by measurements of hospital characteristics including SES patient profile., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Background: The use of national quality campaigns to foster evidence-based hospital practices is increasing. Because campaigns typically do not limit access to their resources, they may influence non-enrolled hospitals as well., Objective: To examine the relative impact of a national campaign, the Door-to-Balloon (D2B) Alliance, on enrolled and non-enrolled hospitals., Methods: In this prospective cohort study, we compared the use of D2B Alliance resources (eg, webinars, online community, mentor network), changes in the use of strategies recommended by the D2B Alliance, and perceived impact of the D2B Alliance between hospitals that enrolled in the D2B Alliance (n=264) and hospitals that declined enrolment (n=101)., Results: More than half (53.2%) of non-enrolled hospitals reported using at least some of the resources made available by the D2B Alliance to improve door-to-balloon times. This compared with 83.5% of enrolled hospitals reporting that they used D2B Alliance resources (p<0.01). Both enrolled and non-enrolled hospitals significantly increased their use of recommended hospital strategies between 2005 and 2008, although the use of strategies remained incomplete (35.5-91.5% use). There was no significant difference between the use of these strategies between enrolled and non-enrolled hospitals at follow-up (p > or = 0.51), adjusted for baseline use. About half of all hospitals reported that door-to-balloon times would have been worse at their hospital without the existence of the D2B Alliance., Conclusions: This research suggests that national quality campaigns with open access to campaign resources may have substantial spillover effects on non-enrolled hospitals.

Despite the clinical importance of prompt percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction, many hospitals do not routinely achieve the guideline-recommended 90-minute door-to-balloon times. In this review, we evaluate existing evidence that identifies effective hospital strategies for reducing door-to-balloon time. We performed a computerized search of MEDLINE and Current Contents for studies conducted in the last 10 years of hospital efforts to improve door-to-balloon times. We excluded studies that had <10 patients, had nonspecific efforts, or, for quantitative studies, lacked statistical tests; each study was independently evaluated by 3 researchers. We found 13 studies that examined the relationship between hospital-based strategies and door-to-balloon times. Three examined national samples of hospitals using cross-sectional designs; 8 were conducted in a single or small number of hospitals using pre/post interventional or cross-sectional designs, and 2 were qualitative in design. Strategies with the strongest evidence include (1) activation of the catheterization laboratory using emergency medicine physicians rather than cardiologists, (2) effective use of prehospital electrocardiograms, (3) performance data monitoring/feedback. Reasonable evidence exists for establishing a single-call system for activating the catheterization laboratory, setting the expectation that the catheterization team be available 20-30 minutes after being paged, and having an organizational environment with strong senior management support and culture to foster changes directed at improving door-to-balloon time. In conclusion, although evidence of "what works" is based on observational studies rather than randomized trials, there is evidence on effective interventions to reduce door-to-balloon time.

Background: The ranking of "America's Best Hospitals" by U.S. News & World Report for "Heart and Heart Surgery" is a popular hospital profiling system, but it is not known if hospitals ranked by the magazine vs nonranked hospitals have lower risk-standardized, 30-day mortality rates (RSMRs) for patients with acute myocardial infarction (AMI)., Methods: Using a hierarchical regression model based on 2003 Medicare administrative data, we calculated RSMRs for ranked and nonranked hospitals in the treatment of AMI. We identified ranked and nonranked hospitals with standardized mortality ratios (SMRs) significantly less than the mean expected for all hospitals in the study., Results: We compared 13 662 patients in 50 ranked hospitals with 254 907 patients in 3813 nonranked hospitals. The RSMRs were lower in ranked vs nonranked hospitals (16.0% vs 17.9%, P<.001). The RSMR range for ranked vs nonranked hospitals overlapped (11.4%-20.0% vs 13.1%-23.3%, respectively). In an RSMR quartile distribution of all hospitals, 35 ranked hospitals (70%) were in the lowest RSMR or best performing quartile, 11 (22%) were in the middle 2 quartiles, and 4 (8%) were in the highest RSMR or worst performing quartile. There were 11 ranked hospitals (22%) and 28 nonranked hospitals (0.73%) that each had an SMR significantly less than 1 (defined by a 95% confidence interval with an upper limit of <1.0)., Conclusions: On average, admission to a ranked hospital for AMI was associated with a lower risk of 30-day mortality, although about one-third of the ranked hospitals fell outside the best performing quartile based on RSMR. Although ranked hospitals were much more likely to have an SMR significantly less than 1, many more nonranked hospitals had this distinction.

Background: The effective translation of scientific evidence into clinical practice is paramount to improving the quality and safety of patient care. However, little is known about the patterns of diffusion of evidence-based programmes in healthcare., Objectives: To study the pattern of diffusion of an evidence-based programme to improve the quality and safety of care for hospitalised older adults., Methods: The diffusion of the Hospital Elder Life Program (HELP), a multifaceted programme to reduce delirium in hospitalised adults, was examined. Using a survey of all hospitals that contacted the HELP Dissemination Project for more than 2 years, the proportion of hospitals that adopted the programme, the programme fidelity to the original design in terms of structure and process, and the perceived reasons for non-adoption were identified., Results: Programme fidelity was highest among structural features (eg, staffing levels); programme modifications were more commonplace in processes of care (eg, the participation of volunteers in patient care interventions). Senior management support and the programme expense were the most commonly cited reasons for non-adoption of HELP., Conclusion: Diffusion and take-up rates for this evidence-based programme were substantial; however, programme fidelity was not complete and some hospitals did not adopt the programme at all. Clinicians, researchers and funding agents seeking to promote effective translation of research should be realistic about diffusion rates and recognise the critical ingredient of senior management support to propel adoption of evidence-based programmes to improve quality and safety.

Context: The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes., Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates., Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data., Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older., Results: We found moderately strong correlations (correlation coefficients > or =0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI., Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

Objectives: The purpose of this study was to analyze recent trends in door-to-reperfusion time and to identify hospital characteristics associated with improved performance., Background: Rapid reperfusion improves survival for patients with acute ST-segment elevation myocardial infarction (STEMI)., Methods: In this retrospective observational study from the National Registry of Myocardial Infarction (NRMI)-3 and -4, between 1999 and 2002, we analyzed door-to-needle and door-to-balloon times in patients admitted with STEMI and receiving fibrinolytic therapy (n = 68,439 patients in 1,015 hospitals) or percutaneous coronary intervention (n = 33,647 patients in 421 hospitals) within 6 h of hospital arrival., Results: In 1999, only 46% of the patients in the fibrinolytic therapy cohort were treated within the recommended 30-min door-to-needle time; only 35% of the patients in the percutaneous coronary intervention cohort were treated within the recommended 90-min door-to-balloon time. Improvement in these times to reperfusion over the four-year study period was not statistically significant (door-to-needle: -0.01 min/year, 95% confidence interval [CI] -0.24 to +0.23, p > 0.9; door-to-balloon: -0.57 min/year, 95% CI -1.24 to +0.10, p = 0.09). Only 33% (337 of 1,015) of hospitals improved door-to-needle time by more than one min/year, and 26% (110 of 421) improved door-to-balloon time by more than three min/year. No hospital characteristic was significantly associated with improvement in door-to-needle time. Only high annual percutaneous coronary intervention volume and location in New England were significantly associated with greater improvement in door-to-balloon time., Conclusions: Fewer than one-half of patients with STEMI receive reperfusion in the recommended door-to-needle or door-to-balloon time, and mean time to reperfusion has not decreased significantly in recent years. Relatively few hospitals have shown substantial improvement.

Context: Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy., Objective: To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality., Design, Setting, and Participants: Cohort study of 68,439 patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy and 33,647 treated with percutaneous coronary intervention (PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours (weekdays, 7 am-5 pm) and off-hours (weekdays 5 pm-7 am and weekends)., Main Outcome Measures: Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics., Results: Most fibrinolytic therapy (67.9%) and PCI patients (54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours (34.3 minutes) than regular hours (33.2 minutes; difference, 1.0 minute; 95% confidence interval [CI], 0.7-1.4; P<.001). In contrast, door-to-balloon times were substantially longer during off-hours (116.1 minutes) than regular hours (94.8 minutes; difference, 21.3 minutes; 95% CI, 20.5-22.2; P<.001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours (25.7%) than regular hours (47%; P<.001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours (41.5%) than regular hours (27.7%; P<.001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory (off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P<.001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours (odds ratio, 1.07; 95% CI, 1.01-1.14; P = .02)., Conclusions: Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.

Objective: To describe the perceived impact of the Centers for Medicare and Medicaid Services Quality Improvement Organizations (QIOs) on quality of care for patients hospitalized with acute myocardial infarction, in the context of new efforts to work more collaboratively with hospitals in the pursuit of quality improvement., Data Source: Primary data collected from a national random sample of 105 hospital quality management directors interviewed between January and July 2002., Study Design: We interviewed quality management directors concerning their interactions with the QIO interventions, the helpfulness of QIO interventions and the degree to which they helped or hindered their hospital quality efforts, and their recommendations for improving QIO effectiveness., Principle Findings: More than 90% of hospitals reported that their QIO had initiated specific interventions, the most common being the provision of educational materials, benchmark data, and hospital performance data. Many respondents (60%) rated most QIO interventions as helpful or very helpful, although only one-quarter of respondents believed quality of care would have been worse without the QIO interventions. To increase QIO efficacy, respondents recommended that QIOs appeal more directly to senior administration, target physicians (not just hospital employees), and enhance the perceived validity and timeliness of data used in quality indicators., Conclusions: Our study demonstrates that the QIOs have overcome, to some degree, the previously adversarial and punitive roles of Peer Review Organizations with hospitals. The generally positive view among most hospital quality improvement directors concerning the QIO interventions suggests that QIOs are potentially poised to take a leading role in promoting quality of care. However, the full potential of QIOs will likely not be realized until QIOs are able to engender greater engagement from senior hospital administration and physicians.

Background: Hospitals are under increasing pressure to measure and improve quality of care, and substantial resources are being directed at a variety of quality improvement strategies; however, the evidence base supporting these strategies is limited., Objective: We sought to identify quality improvement efforts that were associated with hospitals' beta-blocker prescription rates after acute myocardial infarction (AMI)., Research Design: This was a cross-sectional study using data from a telephone survey of quality management directors at participating hospitals linked with patient-level data from the National Registry of Myocardial Infarction (NRMI) during the study period, October 1997 to September 1999., Subjects: A total of 60,363 patients discharged with a confirmed AMI from 234 US hospitals were included., Measures: Hospital performance based on beta-blocker rates characterized as the top 20%, lower 20%, and middle 40% of hospitals; reported quality improvement efforts, including system interventions, physician leadership, administrative support for quality improvement efforts, and data feedback; hospital teaching status, AMI volume, geographic location, and ownership type., Results: The mean hospital-specific beta-blocker rate was 60.2%; however, the variation in beta-blocker use across hospitals was marked (range, 19.4-89.3%, standard deviation, 12.7% points), and quality improvement efforts used varied greatly. None of the quality improvement efforts distinguished higher from medium performers; the higher and the medium performers together were distinguished from the lower performers in organizational support for quality improvement efforts (fully adjusted odds ratio [OR] 1.89, 95% confidence interval [CI] 1.17-3.06) and physician leadership (fully adjusted OR 9.88, 95% CI 2.64-37.02). Among the specific quality improvement interventions, only standing orders were associated with having higher/medium versus lower performance, and their effect had borderline significance (fully adjusted OR 2.26, 95% CI 0.97-5.30, P = 0.07)., Conclusions: Our findings highlight the organizational environment, specifically the absence of administrative support or physician leadership for quality improvement, as an important correlate of poor beta-blocker rates after AMI. Future studies are needed to isolate hospital quality improvement efforts that are associated with superior performance.

Background: Despite the many proposed methods for improving quality, little is known about which methods are being applied in practice across the United States or their perceived effectiveness., Methods: A descriptive, cross-sectional analysis of data from a telephone survey of quality improvement staff in 234 randomly selected hospitals participating in the National Registry of Myocardial Infarction was conducted to examine the prevalence and perceived effectiveness of various quality improvement interventions directed at increasing beta-blocker use after acute myocardial infarction., Results: The mean and median number of quality improvement interventions directed at beta-blocker use in the past 4 years was 5.0 per hospital. The most commonly reported effort was performance reporting about beta-blocker use (87.9%), although only 26.7% used physician-specific performance reporting. More than half the hospitals implemented clinical pathways (58.1%), standing orders (56.8%), or care coordinators (50.4%). Care coordinators (63.4%) and computer support systems (61.6%) were most frequently rated as "very effective." Clinical pathways (24.2%), counseling physicians who had poor performance (26.9%), and reminder forms (23.0%) were most frequently rated as not effective., Conclusions: Substantial variation in the types of quality improvement efforts implemented to increase beta-blocker use and perceived effectiveness were evident.

Background: Ethiopia has one of the highest maternal mortality ratios in Africa. Few have examined the quality of labour and delivery (L&D) care in the country. This study evaluated the quality of routine L&D care and identified patient-level and hospital-level factors associated with the quality of care in a subset of government hospitals. Materials and methods: This was a facility-based, cross-sectional study using direct non-participant observation carried out in 2016. All mothers who received routine L&D care services at government hospitals (n = 20) in one of the populous regions of Ethiopia, Southern Nations Nationalities and People's Region (SNNPR), were included. Mixed effects multilevel linear regression modeling was employed in two stages using hospital as a random effect, with quality of L&D care as the outcome and selected patient and hospital characteristics as independent variables. Patient characteristics included woman's age, number of previous births, number of skilled attendants involved in care process, and presence of any danger sign in current pregnancy. Hospital characteristics included teaching hospital status, mean number of attended births in the previous year, number of fulltime skilled attendants in the L&D ward, whether the hospital had offered refresher training on L&D care in the previous 12 months, and the extent to which the hospital met the 2014 Ethiopian Ministry of Health standards regarding to resources available for providing quality of L&D care (measured on a 0–100% scale). These standards pertain to availability of human resource by category and training status, availability of essential drugs, supplies and equipment in L&D ward, availability of laboratory services and safe blood, and availability of essential guidelines for key L&D care processes. Results: On average, the hospitals met two-thirds of the standards for L&D care quality, with substantial variation between hospitals (standard deviation 10.9 percentage points). While the highest performing hospital met 91.3% of standards, the lowest performing hospital met only 35.8% of the standards. Hospitals had the highest adherence to standards in the domain of immediate and essential newborn care practices (86.8%), followed by the domain of care during the second and third stages of labour (77.9%). Hospitals scored substantially lower in the domains of active management of third stage of labour (AMTSL) (42.2%), interpersonal communication (47.2%), and initial assessment of the woman in labour (59.6%). We found the quality of L&D care score was significantly higher for women who had a history of any danger sign (β = 5.66; p-value = 0.001) and for women who were cared for at a teaching hospital (β = 12.10; p-value = 0.005). Additionally, hospitals with lower volume and more resources available for L&D care (P-values < 0.01) had higher L&D quality scores. Conclusions: Overall, the quality of L&D care provided to labouring mothers at government hospitals in SNNPR was limited. Lack of adherence to standards in the areas of the critical tasks of initial assessment, AMTSL, interpersonal communication during L&D, and respect for women's preferences are especially concerning. Without greater attention to the quality of L&D care, regardless of how accessible hospital L&D care becomes, maternal and neonatal mortality rates are unlikely to decrease substantially. [ABSTRACT FROM AUTHOR]

Background Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. Methods This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. Results We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015. Conclusions Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Hospital quality improvement efforts absorb substantial time and resources, but many innovations fail to integrate into organizational routines, undermining the potential to sustain the new practices. Despite a well-developed literature on the initial implementation of new practices, we have limited knowledge about the mechanisms by which integration occurs.Methods: We conducted a qualitative study using a purposive sample of hospitals that participated in the State Action on Avoidable Rehospitalizations (STAAR) initiative, a collaborative to reduce hospital readmissions that encouraged members to adopt new practices. We selected hospitals where risk-standardized readmission rates (RSRR) had improved (n = 7) or deteriorated (n = 3) over the course of the first 2 years of the STAAR initiative (2010-2011 to 2011-2012) and interviewed a range of staff at each site (90 total). We recruited hospitals until reaching theoretical saturation. The constant comparative method was used to conduct coding and identification of key themes.Results: When innovations were successfully integrated, participants consistently reported that a small number of key staff held the innovation in place for as long as a year while more permanent integrating mechanisms began to work. Depending on characteristics of the innovation, one of three categories of integrating mechanisms eventually took over the role of holding new practices in place. Innovations that proved intrinsically rewarding to the staff, by making their jobs easier or more gratifying, became integrated through shifts in attitudes and norms over time. Innovations for which the staff did not perceive benefits to themselves were integrated through revised performance standards if the innovation involved complex tasks and through automation if the innovation involved simple tasks.Conclusions: Hospitals have an opportunity to promote the integration of new practices by planning for the extended effort required to hold a new practice in place while integration mechanisms take hold. By understanding how integrating mechanisms correspond to innovation characteristics, hospitals may be able to foster integrating mechanisms most likely to work for particular innovations. [ABSTRACT FROM AUTHOR]

Health care organizations often fail in their effort to implement care-improving innovations. This article differentiates role-changing innovations, altering what workers do, from time-changing innovations, altering when tasks are performed or for how long. We examine our hypothesis that the degree to which access to groups that can alter organizational learning--staff, management, and external network--facilitates implementation depends on innovation type. Our longitudinal study using ordinal logistic regression and survey data on 517 hospitals' implementation of evidence-based practices for treating heart attack confirmed our thesis for factors granting access to each group: improvement team's representativeness (of affected staff), senior management engagement, and network membership. Although team representativeness and network membership were positively associated with implementing role-changing practices, senior management engagement was not. In contrast, senior management engagement was positively associated with implementing time-changing practices, whereas team representativeness was not, and network membership was not unless there was limited management engagement. These findings advance implementation science by explaining mixed results across past studies: Nature of change for workers alters potential facilitators' effects on implementation. [ABSTRACT FROM AUTHOR]

The article discusses a study of health care quality at hospitals in U.S. states and in the U.S. territories. The hospitals involved discharged at least one Medicare fee-for-service (FFS) adult diagnosed with acute myocardial infarction (AMI), heart failure (HF) or pneumonia (PNE) from July 2005 to June 2008. Hospitals in the U.S. territories differ from stateside ones in terms of for-profit ownership. Mortality rates are said to be higher in hospitals in the U.S. territories.

The article investigates the delay from the onset of symptoms to hospital presentation for patients with non-ST-segment elevation myocardial infarction (non-STEMI) in 104,622 cases at 568 hospitals in the U.S. from January 1, 2001 to December 31, 2006. The American College of Cardiology/American Heart Association guidelines suggest calling 911 for those experiencing acute coronary syndrome if symptoms do not improve after five minutes. The results show a median delay time of 2.6 hours and cite older age and female sex among reasons for longer delay time.

Objectives: The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation. Background: The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation. Methods: We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008. Results: By March 2008, >75% of patients had D2B times of ≤90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27). Conclusions: The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008. [Copyright &y& Elsevier]

To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults. Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation. Thirteen hospitals implementing HELP. Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews. Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges. Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP. Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine whether having a hospice unit within the hospital increases the proportion of terminally ill patients who use hospice services (including home, nursing home, or inpatient hospice) post-admission. Using medical record data abstracted for 232 randomly selected patients with terminal cancer admitted to six community hospitals in Connecticut, we found that patients admitted to a hospital with a hospice unit were more likely to use hospice services (i.e., home hospice, nursing home hospice, or inpatient hospice) post-admission than patients admitted to a hospital without a hospice unit (unadjusted OR 5.7, 95% CI 3.1, 10.6). This effect persisted after adjusting for patient age, gender, marital status, documented discussions of prognosis, prior hospice use, and type of cancer. [ABSTRACT FROM PUBLISHER]

The authors analyze data submitted by hospitals to the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) which aims to determine whether racial inequality in door-to-balloon (D2B) times decreased over time. Patients were grouped into 12-month intervals for 4 years and patient-level data were calculated. The analysis suggests that racial disparities have decreased over time and that improvement in heath care quality contributed to it.

Many countries struggle to develop and implement strategies to monitor hospitals nationally. The challenge is particularly acute in low-income countries where resources for measurement and reporting are scarce. We examined the experience of developing and implementing a national system for monitoring the performance of 130 government hospitals in Ethiopia. Using participatory observation, we found that the monitoring system resulted in more consistent hospital reporting of performance data to regional health bureaus and the federal government, increased transparency about hospital performance and the development of multiple quality-improvement projects. The development and implementation of the system, which required technical and political investment and support, would not have been possible without strong hospital-level management capacity. Thorough assessment of the health sector's readiness to change and desire to prioritize hospital quality can be helpful in the early stages of design and implementation. This assessment may include interviews with key informants, collection of data about health facilities and human resources and discussion with academic partners. Aligning partners and donors with the government's vision for quality improvement can enhance acceptability and political support. Such alignment can enable resources to be focused strategically towards one national effort -- rather than be diluted across dozens of potentially competing projects. Initial stages benefit from having modest goals and the flexibility for continuous modification and improvement, through active engagement with all stakeholders. [ABSTRACT FROM AUTHOR]

Despite substantial improvement in recent years in hospital performance in many quality measures for acute myocardial infarction (AMI), national performance lags in a key publicly reported quality indicator for AMI--door-to-balloon time, the period from patient (with ST-segment elevation myocardial infarction or STEMI) arrival to provision of percutaneous coronary intervention or balloon angioplasty. Previous research has elucidated distinguishing features of hospitals that routinely achieved recommended door-to-balloon times for patients with STEMI. However, what has not been fully explored is how top-performing hospitals handle setbacks during the improvement process. In this study, we used qualitative methods to characterize the range of setbacks in door-to-balloon improvement efforts and the strategies used to address these barriers among hospitals that were ultimately successful in reducing door-to-balloon time to meet clinical guidelines. Setbacks included (1) failure to anticipate and address implications of initial changes in door-to-balloon processes for the system as a whole; (2) tension between and within departments and disciplines, which needed to gain consensus about how to reduce door-to-balloon time; and (3) waning attention to door-to-balloon performance as a top priority after the perceived goal of reducing treatment times had been reached. Our findings demonstrate key aspects of technical capacity, organizational culture, and environmental conditions that were factors in maintaining improvement efforts despite setbacks and hence may be critical to sustaining top performance. Understanding how top-performing hospitals recognize and respond to setbacks can help senior management promote organizational resiliency, leading to an environment in which learning, growth, and quality improvement can be sustained. [ABSTRACT FROM AUTHOR]