Dr. Khare is an Assistant Professor in the Department of Emergency Medicine and has a secondary appointment at the Institute for Healthcare Studies at Northwestern University. Dr. Khare's long-term goal is to become an independent investigator with a primary focus on improving the care for patients coming to the Emergency Department (ED) with time-sensitive diseases. The ED is a unique healthcare setting that faces significant challenges to achieving high quality care. EDs are often overcrowded, evaluate many patients with undifferentiated, time-sensitive, and complicated diseases, and cannot schedule, predict, nor effectively limit the number and types of patients seeking care. Dr. Khare hypothesizes that high quality ED care and patient outcomes involve (1) efficient operations (e.g., keeping the time a patient arrives to the ED to when they see a physician at a minimum) and (2) robust, standardized quality management approaches (e.g., self-directed quality improvement processes, aimed at evaluating an individual hospital's deficiencies). Variation in both operations and quality management may explain, in part, why similar hospitals vary so dramatically on quality indicator scores and outcomes. The objectives of this project are to further evaluate specific ED operational quality management characteristics to identify and implement generalizable process improvements to enhance quality and safety in EDs. For this project, Dr. Khare will focus on one key quality indicator score in the ED: time-to- percutaneous intervention (PCI) quality indicator score for acute ST-elevation myocardial infarction (STEMI) patients. Patients with STEMI have increased mortality if reperfusion or PCI is not achieved within 90 minutes. Although there is an extensive literature about implementation of this process, the time-to-PCI quality indicator is achieved only 70% of the time. With this award, Dr. Khare intends to gain the skills and knowledge necessary to become a future national leader in ED quality and patient safety research. To fulfill this goal, he will: (1) develop skills in quantitative research methods by combining several large databases to evaluate the correlation between ED operational characteristics and acute myocardial infarction mortality; (2) develop skills in qualitative research methods through the use of a Failure Mode and Effects and Criticality Analysis, to understand the quality management characteristics necessary to achieve optimal quality scores for time-to-PCI; (3) develop and implement process improvements to address the most serious time-to PCI process concerns; and (4) develop a toolkit, based on the findings of 1, 2, and 3, that will assist hospitals and EDs in assessing opportunities for operational improvement and offer an approach for assessing and resolving quality management issues for time-to-PCI. PUBLIC HEALTH RELEVANCE: This study will fill an important gap in knowledge and understanding of the quality and safety of a complex, high acuity, and time-dependent process - achieving life-saving treatments for patients with heart attacks in an efficient manner. Currently, there is considerable pressure to efficiently provide the right treatment, for the right patient, at the right time, specifically giving excellent care to patients with heart attacks. Giving excellent healthcare to patients needs to be done in the emergency department, an environment that is often overcrowded and takes care of patients with many complicated diseases. Thus, evaluation of the way emergency departments operate and their quality management approaches must be rigorously studied and enhanced to provide the best care to the American people.