OBJECTIVE: To examine structural and organizational characteristics at two ICUs with marked differences in risk-adjusted survival. METHODS: We performed on-site organizational analysis in two ICUs at two major teaching hospitals. Our main outcome measures were interviews and direct observations by a team of clinical and organizational researchers; demographic, clinical, and survival data for 888 ICU admissions; and questionnaire responses from 70 nurses and 42 physicians on ICU structure and organization. ICU performance was measured using risk-adjusted survival and the ratios of actual to predicted ICU length of stay and resource use. RESULTS: Structural and organizational questionnaires, self-evaluation by staff members, and the research team's implicit judgments following detailed on-site analysis failed to distinguish units with higher and lower risk-adjusted survival. Both units exhibited practices to emulate and practices to avoid. CONCLUSIONS: The methods used in this study can identify organizational problems and potential means for improvement. The best practices and suggestions for improvement at these units provide examples of methods for improving ICU management.

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