Table 3.

Organizational and Team-Level Determinants of Effective Care for Patients Receiving Prolonged Mechanical Ventilation

Domain	Attributes of High-Performing Hospitals	Attributes of Low-Performing Hospitals
Leadership	Leadership teams communicate a clear message of quality improvement that filters to every level of the organization; provide staff with supervisory support that allows profession-specific continuing education and expert knowledge; and promote a sense of collaboration and support	Leadership teams implement inconsistent, occasionally punitive quality improvement; exhibit oversight creep; and promote a work environment with clear demarcation between management and staff
	Leaders are present in care areas, routinely engaging frontline care providers	Leaders are absent from care areas and unrecognizable by staff
Physician staffing	Physician or advanced practice provider is available 24 h/d, 7 d/wk. Physician care provided by a single physician group, facilitating a consistent “style”	No nighttime physician care. Physician care provided by multiple groups with inconsistent communication practices and care styles
	Physicians are dedicated to the hospital with no other care responsibilities on that day	Physicians consult patients in an ad hoc manner, communicating via notes rather than in-person communication
Nurse staffing	Lower nurse-to-patient ratios (e.g., 1:4)	Higher nurse-to-patient ratios (e.g., 1:6)
	Turnover is present but actively managed through recruitment and retention programs. In some cases, this took the form of “nurse residency” programs to allow nurses to acclimate to patients with prolonged mechanical ventilation	Turnover is present but not actively managed. Training is for the most part “on the job,” with minimal attention to mentorship and retention
Respiratory, physical, and occupational therapy staffing	Relatively large staff enabling patients to be seen every day and for long periods of time, with the flexibility to focus care on the patients with greatest need	Relatively small therapy staff such that only a subset of patients are seen and with less consistency
	Overall staffing levels are sufficient to allow continuity of care (i.e., the same care providers across multiple days), enabling consistent delivery of complex care plans. Staff assignments are made with attention to continuity and designed to reinforce established relationships	Goals of care are established by a physical or occupational therapist while daily therapy is provided by therapy assistants
Ancillary staffing	Dietitians, wound care, pharmacist, and other staff members are fully integrated into the care teams	Other staff are disconnected from the care team, working in parallel
	Resources are readily available to support emotional needs, such as psychologists and spiritual care	More reliance on medication to treat emotional needs, with less readily available psychologists and/or spiritual care
Protocols and care pathways	Profession-driven weaning protocols, which provide autonomy and empowerment among care providers	Weaning protocols were vague, with most direction provided by physicians, limiting empowerment
	Protocols explicitly linked different provider types to encourage collaboration	Protocols were unique to individual provider types, obviating the need for collaboration to enforce the protocol
	Care pathways enable nonphysician providers to initiate care, preventing delays and ensuring the highest-priority needs are met	Care pathways rely on physician orders, creating delays and preventing optimal prioritization of care
	Goals are dynamic and adaptable to patient needs or progress. Protocols are specific, but patients occasionally go “off protocol” after discussion by the care team	Patient-specific goals are either nonexistent or discretionary, making it challenging for other members of the care team to stay up-to-date with daily plans. Protocols, if they exist, are general to the point that they function more as guidelines than as specific decision-making tools
Team meetings	Weekly interdisciplinary team meetings included direct care providers and were used to troubleshoot and problem solve rather than just to exchange information. Active involvement of physicians and/or pulmonologists in team discussions	Weekly team meetings rarely include direct care providers. Meeting content is based on rote reports with limited time for troubleshooting and problem solving. Physicians and/or pulmonologists mostly listen and sign documents
	Frequent, informal interprofessional meetings (i.e., “morning huddles”), either daily or sporadically throughout the week	Additional interprofessional meetings outside standard meetings are rare
Physical plant	Workspaces separate from but geographically proximal to clinical areas, allowing professionals to informally interact	No dedicated workspace or workspaces near patient care areas
	Patient care areas contain large workstations, allowing groups to interact	Workstations are small, forcing providers to disburse, inhibiting communication
	Patient rooms can comfortably accommodate families	Patient rooms are small, making family accommodation difficult