Critical care outcomes: linking structures, processes, and organizational and clinical outcomes

Abstract

Organizational structure and process are thought to affect patient care outcomes beyond the effects of expert clinical care. To test the hypothesis that a discretionary pattern of organizational structure and process factors is predictive of critical care unit performance, ie, desirable patient and organizational outcomes. Quality-of-care patient and organizational outcomes were evaluated in 25 critical care units. A single value representing each critical care unit's euclidian distance from a theoretically ideal pattern of discretionary function was determined and correlated with unit-level measures of outcomes (standardized mortality ratio, severity-adjusted length of stay, patient satisfaction, quality of nursing care, and nursing retention). Distance from the ideal-type discretionary pattern predicted organizational but not clinical outcomes. Units closer to the ideal-type pattern had higher RN retention, and were viewed as better places to work, with higher-quality care by both nurses and physicians. Objectively measured quality of care, patient satisfaction, severity-adjusted mortality, and length of stay were not consistently related to better-structured units. With experienced critical care practitioners, unit-level structure and process factors were better predictors of organizational outcomes than of clinical outcomes.