BACKGROUND: Organizational structure and process are thought to affect
patient care outcomes beyond the effects of expert clinical care.
OBJECTIVES: 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.
METHODS: 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). RESULTS: 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.
CONCLUSIONS: With experienced critical care practitioners, unit-level
structure and process factors were better predictors of organizational
outcomes than of clinical outcomes.
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