Adverse outcomes and variations in organization of care delivery

OBJECTIVES. This article evaluates the state of the science with respect to morbidity, mortality, and adverse effects as outcomes indicative of variations in organizational variables in care delivery systems. METHODS. Eighty-one research papers research examining relations among organizational structures or processes and mortality/adverse effects were reviewed, assembled from electronic and manual searches of the biomedical and health services research literature. RESULTS. Most research relating mortality and other adverse outcomes to organizational variables has been conducted in acute care hospitals since 1990, with these outcome indictors linked more frequently to organizational structures than to organizational or clinical processes. There is support in some studies, but not in others, that nursing surveillance, quality of working environment, and quality of interaction with other professionals distinguish hospitals with lower mortality and complications from those with higher rates of these adverse effects. Increasing sophistication of risk adjustment methods suggests that variations in mortality and complications are influenced by patient variables more than by organizational variables. Adverse events may be a more sensitive marker of differences in organizational quality in acute care hospitals and long-term care. CONCLUSIONS. Taken together, the acute care studies are not conclusive regarding the extent to which the organizational features of care delivery systems positively influence such bottom-line outcomes as mortality. As severity-adjustment methods become more refined for hospital patients, many of the small differences currently seen in mortality and complications may disappear. However, given that adverse events appear more closely related to organizational factors than is mortality, researchers need to refine and better define such events that are logically related to the coordinative organizational processes among caregivers. Finally, researchers need to go much beyond mortality, morbidity, and adverse events in evaluating the linkage between the organization of care and outcomes.