Focusing on the processes of care at the top-performing institutions, research has revealed characteristics of institutions associated with Top hospitals have specific cultural attributes that include 1) a commitment to an explicit goal of improving D2B times that is motivated by internal and external pressures, including senior management support; 2) innova- tive protocols; 3) flexibility in refining standardized protocols; 4) uncompromising individual clinical leaders; 5) collab- orative teams; 6) data feedback to monitor progress, identify problems, and successes; and 7) an organizational culture that fosters resilience to challenges or setbacks to improvement In addition, several key processes are associated strongly with more timely treatment (Checklist). Other studies have indicated that PCI-capable hospitals receiving patients in transfer can reduce their D2B times by coordinating with the referring hospitals and activating their systems while patients are being transported.78 Currently, it is estimated that almost 90% of patients presenting to a hospital with PCI capability and without a clinical reason for delay have a D2B time 90 minutes.136 Some innovative programs are achieving much faster In addition, with improvements in timeliness of care across the country, racial disparities in reperfusion times have been reduced significantly.140 In an analysis of patients with STEMI reported by hospitals to the Centers for Medicare & Medicaid Services, median D2B times fell from 96 minutes in the year ending December 31, 2005, to 64 minutes in the 3 quarters ending September 30, 2010. This decline was accompanied by an increase in the percent- age of patients with D2B times <90 minutes, from 44.2% to Nevertheless, despite substantial improvements in D2B times, evidence that these efforts have translated into reduced mortality rates is lacking. The absence of demon- strated benefit may relate to reduced power to show change in Checklist. 