Impact of Cardiac Cath Lab Organization on Process and Outcome Quality : A Case Study

Quality improvement must balance two conflicting objectives: process conformance and process re-engineering. Healthcare facility organization structure may favor one approach over the other. We examined whether cardiac cath labs that are open [permitting operators to work at other sites] or closed achieve faster door-to-balloon times [D2B] and lower in-hospital mortality. We used retrospective secondary data from the Massachusetts Department of Public Health on all 30,903 cath lab visits involving a percutaneous coronary intervention [PCI] in 4/1/03-12/31/04. Patient-level models were estimated for in-hospital mortality in all patients, and for D2B time in ST-segment elevation myocardial infarction [STEMI] patients, accounting for patient risk, hospital and operator PCI procedural volume.The parameters of interest were the effects of a lab's closed status or the by the mean number of labs where an open lab's operators worked across. In unadjusted analyses, the patients of closed labs had lower in-hospital mortality (1.0% vs. 1.7%, P<.001), and their STEMI patients had longer median D2B times (96 vs. 73 minutes, P<.001). The more open a lab, the faster were D2B times and the higher the proportions of patients meeting D2b thresholds (trend, P<.001). Procedural experience was not consistently related to mortality outcomes. In adjusted analyses, STEMI patients of closed labs had lower odds of timely PCI <30 min (P<.05) and <60 min (P<.01); the more open a lab, the better the odds (all, P<.001). In hierarchical mixed models, STEMI patients continued to have lower odds of PCI <30 min (P=0.064) and <60 min (P<.05) the more open their labs were.Patients of closed and less open cath labs in Massachusetts were less likely to receive timely PCI, but not more or less likely to die in hospital. Hospital and operator PCI experience was inconsistently associated with D2B times. This case study's findings support a broader search for the success factors of PCI quality beyond experience or site processes towards aspects of a lab's organization and staffing pattern