Kelly J. Devers

Organizational assessment in intensive care units (ICUs): construct development, reliability, and validity of the ICU nurse-physician questionnaire.

Health Services Research has a growing need for reliable and valid measures of managerial practices and organizational processes. A national study of 42 intensive care units involving over 1,700 respondents provides evidence for the reliability and validity of a comprehensive set of measures related to leadership, organizational culture, communication, coordination, problem solving-conflict management and team cohesiveness. The data also support the appropriateness of aggregating individual respondent data to the unit level. Implications for further research are discussed.

Improving intensive care : observations based on organizational case studies in nine intensive care units : a prospective, multicenter study

To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance. Design:Prospective 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. Participants:A sample of 3,672 ICU admissions; 316 nurses and 202 physicians. Materials and Methods:Interviews and direct observations by a team of clinical and organizational researchers. Demographic, physiologic, and outcome data for an average of 408 admissions per ICU; and questionnaires on ICU structure and organization. The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness; the ratio of actual/predicted length of ICU stay was used to assess efficiency. Measurements and Main Results:ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational questionnaires or by global judgment following on-site analysis. Superior organizational practices among these ICUs were related to a patient-centered culture, strong medical and nursing leadership, effective communication and coordination, and open, collaborative approaches to solving problems and managing conflict. Conclusions:The best and worst organizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management. (Crit Care Med 1993; 21:1443–1451)

Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study.

ObjectiveTo examine variations in case-mix, structure, resource use, and outcome performance among teaching and nonteaching intensive care units (ICU). Design:Prospective inception cohort study. Patients: Aconsecutive sample of 15,297 patients at 35 hospitals, which compared 8,269 patients admitted to 20 teaching ICUs at 18 hospitals vs. 7,028 patients admitted to 17 non-teaching ICUs at 17 hospitals. Interventions:None. Measurements:We selected demographic, physiologic, and treatment information for an average of 415 patients at each ICU, and collected data on hospital and ICU structure. Outcomes were compared using ratios of observed to risk-adjusted predicted hospital death rates, ICU length of stay, and resource use. Main Results:When compared to nonteaching ICUs, teaching ICUs had twice the number of physicians who regulary provided services and cared for significantly younger and more severely ill (p < .001) patients. Risk-adjusted ICU length of stay was similar, but resource use was significantly (p < .001) greater in teaching ICUs, with

Implementing organized delivery systems: an integration scorecard.

3,000 (10.5%) of estimated total costs for an average ICU admission related to increased use of diagnostic testing and invasive procedures in teaching ICUs. Risk-adjusted hospital death rates were not significantly different (p = .1) between all teaching and nonteaching ICUs, but were significantly (p < .05) better in four teaching ICUs, but in only one nonteaching ICU. The 14 hospitals that were members of the Council of Teaching Hospitals had significantly better risk-adjusted outcome in their 16 ICUs than all others (odds ratio = 1.21, confidence interval 1.06 to 1.38, p = .004). Conclusions:Teaching ICUs care for more complex patients in a substantially more complicated organizational setting. The best risk-adjusted survival rates occur at teaching ICUs, but production cost is higher in teaching units, secondary to increased testing and therapy. Teaching ICUs are also successfully transferring knowledge to trainees who, after their training, are achieving equivalent results at slightly lower cost in nonteaching ICUs. (Crit Care Med 1993; 21:1432–1442)

Continuously improving patient care: practical lessons and an assessment tool from the National ICU Study.

Organized vertically integrated health systems are in a key position to play a major role in present health care reform efforts. To demonstrate a competitive advantage in the new health care environment, however, integration efforts must be successful. Based on a national study of nine organized delivery systems, this article develops measures of three types of integration that occur in vertically integrated health systems—functional, physician-system, and clinical. These measures can be used as a “scorecard” to assess progress toward achieving integration objectives.

Variations in inpatient mortality among hospitals in different system types, 1995 to 2000.

Pressure for hospitals to maintain quality while lowering cost or provide greater quality at a given level of cost is particularly critical in intensive care services for which it is increasingly difficult to match revenues with costs, given reimbursement limits. At the same time, twofold to threefold differences in intensive care unit risk-adjusted mortality have been reported. This article provides a model for thinking about continuous improvement of intensive care services, draws on the National ICU Study to identify fundamental organizational and managerial processes associated with better performance, and offers a validated assessment instrument to be used as a tool for continuous improvement.

Reinventing the American hospital.

Background:Relatively few studies focused on the impact of system formation and hospital merger on quality, and these studies reported typically little or no quality effect. Objective:To study associations among 5 main types of health systems–centralized, centralized physician/insurance, moderately centralized, decentralized, and independent–and inpatient mortality from acute myocardial infarction (AMI), congestive heart failure, stroke, and pneumonia. Data and Methods:Panel data (1995–2000) were assembled from 11 states and multiple sources: Agency for Healthcare Research and Quality State Inpatient Database, American Hospital Association Annual Surveys, Area Resource File, HMO InterStudy, and the Centers for Medicare and Medicaid Services. We applied a panel study design with fixed effects models using information on variation within hospitals. Results:We found that centralized health systems are associated with lower AMI, congestive heart failure, and pneumonia mortality. Independent hospital systems had better AMI quality outcomes than centralized physician/insurance and moderately centralized health systems. We found no difference in inpatient mortality among system types for the stroke outcome. Thus, for certain types of clinical service lines and patients, hospital system type matters. Research that focuses only on system membership may mask the impact of system type on the quality of care.