THE RELATIONSHIP BETWEEN ORGANIZATIONAL FACTORS AND TIMELY CARDIAC CATHETETRIZATION RATE IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION PATIENTS OF HOSPITALS IN THAILAND

Introduction: This descriptive study aimed to study an association between the level of readiness of administrative factors and the timely cardiac catheterization rate of patients with acute ischemic heart disease in hospitals in Thailand. Materials and methods: The target population was 1,180 hospitals that serving heart disease in Thailand. Data were collected by using a questionnaire. A total of 1,022 response data were obtained. The statistics used to analyze the data were frequency, percentage, mean, standard deviation, and correlation was analyzed by multiple regression analysis. Results: The organizational factors, which consisted of personnel, finance, supporting, and management factors, had overall average readiness at a high level (x̄ = 3.34, S.D. = 0.27). While budget sufficiency was at a low level (x̄ = 2.43, S.D. = 0.43). All factors were significantly related to the timely cardiac catheterization rate, as follows: management factor (Adjust R2 = 0.442), personnel factor (Adjust R2 = 0.244), supporting factor (Adjust R2 = 0.212) and financial factor (Adjust R2 = 0.091). Conclusion: Therefore, the Thai Ministry of Public Health should provide adequate support for organizational factors, especially in terms of budget sufficiency.

INTRODUCTION Coronary heart disease is a lifethreatening emergency and a serious public health issue globally, particularly in Thailand. According to World Health Organization (WHO) estimates from 2012, ischemic heart disease was responsible for 7.4 million deaths worldwide, accounting for 12.2 % of all causes of death. The number of fatalities from coronary heart disease increased to 17.9 million in 2018, accounting for 31% of all causes of death worldwide [1]. According to data from the Thai Ministry of Public Health, the rate of death from coronary heart disease in Thailand in 2017 was 31.8 per Acute ischemic heart disease is caused by blood clots occluding the coronary artery. This causes a myocardial infarction, which frequently presents with immediate symptoms. Especially if electrocardiogram (ECG) anomalies in the ST segment rose, at least two consecutive leads are discovered, which is known as ST-Elevation Myocardial Infarction (STEMI) [3]. If the obstructed artery is not opened quickly, sudden death is a risk [4]. Treatment according to the guidelines of the European Heart Association 2017 edition [5] and the Heart Association of Thailand 2020 edition [3] have determined that this group of patients should receive cardiac catheterization (Primary Percutaneous Coronary Intervention; Primary PCI) within 120 minutes [6] as if treated later than that time myocardial may cause permanent injury and death [7,8,9]. An effective referral system is very important because most hospitals in Thailand do not have cardiac catheterization centers, especially in rural areas. The Thai Ministry of Public Health divided the area of responsibility of the cardiac referral system into 13 health service areas according to the criteria of the Thai National Health Security Office (NHSO) [10] as shown in table 1, according to the NHSO has set a target (Key Performance Index: KPI) rate of receiving treatment by Primary Percutaneous Coronary Intervention (Primary PCI) within 120 minutes, more than 50 % as criteria. But in 2017, the overall timely catheterization rate of patients with acute STEMI was only 30 % [11].
The referral system for acute STEMI patients cannot operate effectively without the readiness of organizational factors, including Personnel (Man), Finance (Money), Supporting Factors (Material), and Management (Method), which are critical factors. Methodical management of these resource utilization ensures efficient and effective work [12,13,14]. Considering the problems mentioned above, we planned this study with the following research questions: Are the Administrative/organizational factors of hospitals in Thailand, for acute STEMI patients, readiness or not? Which Administrative/organization factors affect the timely catheterization rate of this referral system?

MATERIAL AND METHODS Study Design and Population
This research was a correlation study conducted for three months, from October to December 2020. The research population is 1,180 hospitals under the Ministry of Public Health and private hospitals that are cardiology service units of the Thai Ministry of Public Health.
Health service area OBJECTIVES 1. To study the level of readiness of the organizational factors of the STEMI referral system in Thai hospitals. 2. To study the organizational factors that affect the timely cardiac catheterization rate of STEMI patients in Thai hospitals.

Data Collection and Analysis Data collection
This research was a descriptive correlation study. The questionnaire was used as closed-end questions with a 5level rating scale on the readiness of organizational factors of personnel, finance, supporting factors, and management by designating the hospital directors to represent the hospitals. Secondary data during 2018-2019 on the mortality rate of acute STEMI patients were collected from the Thai Ministry of Health report.

Data Analysis
Data was entered into excel version 13 and was analyzed using SPSS 25 according to the objectives as follows: Objective 1: To study the level of readiness of the organizational factors of the STEMI referral system in Thai hospitals by content analysis with descriptive statistics, frequency, percentage, mean (x), and standard deviation (S.D.) Interpreting the questionnaire results using an interval scale by dividing the level of readiness of organizational factors as follows; the average score of 4.21 -5.00 means "highest level of readiness," average score of 3.41 -4.20 means " high level of readiness," average score of 2.61 -3.40 mean "moderate readiness," average score of 1.81 -2.60 mean "low readiness," and the average score of 1.00 -1.80 mean "lowest readiness. " The timely cardiac catheterization rate of patients with acute STEMI is presented by descriptive statistics, frequency, and percentage.

Objective 2.
To study organizational factors affecting timely cardiac catheterization rate of patients with acute STEMI of hospitals in Thailand by using Multiple Regression Analysis methods (MRA).

RESULTS
From the analysis of opinions about readiness in personnel, finance, supporting, and management factors from the directors of hospitals in Thailand by questionnaire to all 1,180 hospitals, a total of 1,022 responses was obtained. It was found that most of the respondents were male (98.7 %) and had an average age of over 50 years (46.1 %). 88.5% were specialist doctors. 41.6% have work experience in 6-15 years. All respondents had a current position as a hospital director, as Table 2 Table 2 Number and percentage of the baseline characteristic of the respondents.
Respondents were 119 hospitals (11.64%) in the 13th health service area (Bangkok), followed by 93 hospitals (9.09%) in both 6 th (Rayong) and 9 th health service area (Nakhon Ratchasima), and only 50 hospitals (4.89%) from 3 rd health service area (Nakhon Sawan). 41.87% (428) were hospitals in the area with a moderate proportion of the number of cardiac catheterization centers to the number of hospitals in the area (5-10 %), 34.95% (357) were representatives from the large proportion group (> 10%), 23.18% (237) were representatives from small proportion group (< 5 %  Table 3 Number and percentage of hospitals in the referral system classified by characteristics of hospitals.  Table 4. Analysis of the relationship between readiness factors of various administrative factors, which consist of personnel, finance, supporting, and management factors that affect the timely cardiac catheterization rate by using the Multiple Regression Analysis (MRA), the results are summarized in Table 5-8. Table 5 shows that recruitment, training, and maintenance were correlated with timely cardiac catheterization rate with statistically significant. Table 6 shows that the adequacy of the budget, audit, and control system correlated with timely catheterization rate while appropriateness was not related to timely catheterization rate.     Table 7 Analysis of the relationship between readiness of supporting factor and timely cardiac catheterization rate. Table 7 shows that medical equipment, medicine, medical supply, and ambulance correlated with timely cardiac catheterization rate. Table 8 that process, risk management, and network were correlated with timely cardiac catheterization rate while working step, route, and technology were not related to timely cardiac catheterization rate.

The readiness of organizational factors and the timely cardiac catheterization in the acute STEMI referral system of hospitals in Thailand.
Administrative with the 4 M concept is essential to productive work. If there is a lack of good management, this will cause obstacles and result in unsuccessful work. All types of management are necessary to rely on the factors of personnel (Man), finance (Money), supporting factor (Material), and management (Method) as elements to promote and support work results to achieve goals [15]. This research data found that the referral system for patients with acute STEMI of hospitals in Thailand still facing a lack of budgets. Similarly, with the study of Sriphontan (2017: 23-30) [16], which found the problem of referral system of cardiac patients in Thailand (Phanom Sarakham province), there is a lack of funding sources and budgets to provide quality medical equipment, as well as the results of the study of Wisaphan et al. (2017: 199) [13], which study the management model of the referral network of Thailand (Chanthaburi Province) by qualitative research, found that in addition to the problem of the sufficiency of the budget, there is also the problem of planning for the use of the hospital's budget for work development, there are no plans/projects that provide specific details.
Effectiveness of the STEMI referral system of hospitals in Thailand during the year 2018 [17], the overall rate of timely coronary catheterization rate was 51% with a median of 170 minutes. The longest delay was 363 minutes in the 10th health service area (Ubon Ratchathani  Table 8 Analysis of the relationship between readiness of management factor and timely cardiac catheterization rate. should focus on 1) the referral process, 2) the referral network, and 3) the management of risks during transport. This is consistent with the previous study by Rojprasert (2013: 70) [19] suggested that the development of the management system for the Thai referral system at the policy level are 1) to develop an information system to be up-to-date, easy to use, convenient, and linking access to current information, 2) having to seek a coalition outside the ministry, 3) in case of government hospitals which affiliated with multiple ministries, the ministry which has the main mission should coordinate the referral policy, 4) The technology system must be established thoroughly that personnel can access information easily, conveniently, quickly, can link information online immediately and have flexibility in communicating information for referrals to patients.
Personnel factors should focus on 1) recruiting, 2) training and development, and 3) maintenance. The personnel factor is very important; according to Puchakan (1991) [20], personnel is critical in management because personnel is users of other factors. If the hospital has personnel with knowledge and abilities, they will make the organization progress.
Supporting factors should focus on the development of 1) medical equipment, 2) medicine and medical supply, and 3) ambulance for referrals consistent with the study of Wisaphan et al. (2017: 199) [13], who said that the readiness of medical equipment, vehicles, in-vehicle equipment is an important factor in the management of referrals, because it is a tool for working towards the specified destination.
The financial factor should focus on 1) budget sufficiency, especially the compensation for the performance of personnel and the budget for providing medical devices with good quantity and quality. And 2) Audit and control system. This is correlated with the recommendation of Kwathai (2014) [21] has studied the performance of public health officials and found that the sufficient budget amount of money has a high level of relationship (63.30%) to the performance of health workers. Therefore, it can be concluded that money is another administrative resource that helps other mechanisms in the management system to be more flexible.

RECOMMENDATION
1. Ministry of Public Health of Thailand should provide the necessary medical equipment to treat acute coronary artery disease, such as more cardiac catheterization rooms throughout the country.
2. In addition to providing adequate cardiac catheterization, the Ministry of Public Health of Thailand should be developing policies to increase the readiness of organizational factors that significantly affect timely cardiac catheterization rates, such as focusing on the management factor by improving referral network and risk management, and referral process. For personnel factors, they should focus on staff training and compensation of personnel. For supporting factors, they should focus on increasing the medical equipment and ambulance. For the financial factor, they should increase the budget to support the cardiac referral system.

Conflicts of Interests
The research received no specific grant from any funding agency in public, commercial or not-for-profit sectors. The author declared no conflicts of interest.