• P H Mitchell, S E Shannon, K C Cain, and S T Hegyvary.
• School of Nursing, University of Washington, Seattle, USA.
• Am. J. Crit. Care. 1996 Sep 1;5(5):353-63, quiz 364-5.

BackgroundOrganizational structure and process are thought to affect patient care outcomes beyond the effects of expert clinical care.ObjectivesTo 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.MethodsQuality-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).ResultsDistance 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.ConclusionsWith experienced critical care practitioners, unit-level structure and process factors were better predictors of organizational outcomes than of clinical outcomes.

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