IMPROVING INTENSIVE-CARE - OBSERVATIONS BASED ON ORGANIZATIONAL CASE-STUDIES IN 9 INTENSIVE-CARE UNITS - A PROSPECTIVE, MULTICENTER STUDY

Objective. To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance. Design: Prosp ective multicenter study. On-site organizational analysis; prospective inception cohort. Setting. Nine ICUs (one medical, two surgical, six medical-surgical) at five teaching and four nonteaching hospitals. Par ticipants: A sample of 3,672 ICU admissions; 316 nurses and 202 physic ians.Materials and Methods. Interviews and direct observations by a te am of clinical and organizational researchers. Demographic, physiologi c, and outcome data for an average of 408 admissions per ICU; and ques tionnaires on ICU structure and organization. The ratio of actual/pred icted hospital death rate was used to measure ICU effectiveness; the r atio of actual/predicted length of ICU stay was used to assess efficie ncy. Measurements and Main Results: ICUs with superior risk-adjusted s urvival could not be distinguished by structural and organizational qu estionnaires or by global judgment following on-site analysis. Superio r organizational practices among these ICUs were related to a patient- centered culture, strong medical and nursing leadership, effective com munication and coordination, and open, collaborative approaches to sol ving problems and managing conflict. Conclusions: The best and worst o rganizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management.