1. 1 Redesigning Hospitals to Improve Quality The Door-to-Balloon A lliance Elizabeth H. Bradley, PhD Professor of Public Health Yale School of Public Health

2. 2 Acknowledgements Commonwealth Fund National Heart, Lung, and Blood Institute Donaghue Medical Research Foundation

3. 3 Background Gaps in care, even in cardiology where: - Evidence of best practices is excellent - Cardiac conditions are prevalent - Market is lucrative for physicians & hospitals - Performance is publicly reported What else is needed? - Organizational improvement efforts

4. 4 Example: Treatment of ST elevation myocardial infarction

5. 5 Primary PCI for STEMI is a remarkable intervention

6. 6 But time matters

7. 7 Substantial variation across hospitals

8. 8 How do the best hospitals do it?

9. 9 A “positive deviance” approach 1.Identify top performing hospitals 2.Study them qualitatively 3. Generate hypotheses about top performance 4. Test hypotheses quantitatively with national sample of hospitals 5. Disseminate evidence in national campaign

10. 10 Several simple key strategies were identified to reduce door-to-balloon time

11. 11 The D2B Alliance Goal: 75% of cases < 90 minutes

12. 12 More than 1,000 hospitals enrolled

13. 13 What has changed? Strategy 2006/72008 % chg EM activates lab51.6%60.5%17% Single call30.1%37.7%25% Cath team w/in 30 mins78.9%98.4%25% Prompt data feedback56.8%75.7%33% --------- OPTIONAL Activate from field29.7%37.7% 27%

14. 14 Who joined? Larger (300+ versus < 300 beds) Teaching (versus non-teaching) Non-profit (versus for-profit) Early joiners: significantly more likely to already have strategies in place Bradley et al., Joint Comm J, in press

15. 15 What did the D2B Alliance do for hospitals? The D2B Alliance legitimized strategies that had been controversial (ED activation) The D2B Alliance fostered teamwork to address a common challenge  QI culture The D2B Alliance created a network for learning and teaching

16. 16 The perfect storm… Sense of urgency: new performance target to be publicly reported in a profitable service Physician champions (sponsored by ACC) Timely scientific evidence about what works D2B Alliance to promote hospital change

17. 17 Sustaining change after the D2B Alliance Organizational resilience to setbacks Common setback types - An unexpected glitch in the process - Tension between groups - Waning attention to issue Webster et al., JHCM, 2008

18. 18 Hospital responses to setbacks A glitch in the process, unexpected  go back to the data and QI tools Tension between groups  dialogue and face-to-face meetings; involvement of senior management to hold accountable Waning attention to issue  invoke external pressure or fear of market or regulation Webster et al., JHCM, 2008

19. 19 Conclusion Multiple levers for change  New economic incentives  New regulatory incentives  New scientific evidence  Organizationally-based interventions

20. 20 Thank you