Background. The persistently critically ill—patients who remain in the intensive care unit (ICU) for at least 11 days—comprise 5% of ICU patients but account for 21% of ICU bed-days in the Veterans Health Administration (VHA). Nearly half of patients with persistent critical illness (PerCI) die in the subsequent year, and survivors are often left with new cognitive and/or physical impairments. There is an urgent need to identify strategies to improve quality of life (QoL) outcomes and survivorship for Veterans with PerCI. Significance. IMPROVE PerCI directly aligns with the VHA's Whole Health Initiative and Strategic Priorities for Research by prioritizing what matters to Veterans and their caregivers. Veteran-centered QoL outcomes are of particular importance and relevance following a hospitalization with PerCI. We recognize that simply focusing on mortality fails to acknowledge the impact these prolonged hospitalizations can have on the Veterans QoL. Identifying how variation in organizational care practices can lead to improved QoL outcomes for Veterans is essential. Importantly, the VHA provides care across the continuum from inpatient hospitalizations to outpatient follow-up visits, offering opportunities to identify innovative strategies to delivering Veteran centered care which improves their QoL. Innovation and Impact. IMPROVE PerCI is innovative in four specific ways. First, this will be the first national study of Veterans with PerCI and their caregivers to evaluate their QoL outcomes. Second, we will evaluate organizational mechanisms that differ among high- and low- performing VHA hospitals. Third, we will evaluate organizational practices at high performing survivorship VHAs through an implementation framework to readily translate practices into actionable recommendations. Lastly, we will use an innovative causal modeling approach, coincidence analysis, to evaluate the causality of the multifaceted practices implemented within VHA hospitals. Specific Aims. (A1) Identify high- and low-performing VHA hospitals for survival among Veterans with PerCI and understand the extent to which organizational factors differ. (A2) Elicit Veteran- and caregiver-survivorship experiences and QoL outcomes. (A3) Identify and define `best practices' at high-performing QoL VHA hospitals through detailed contextual hospital assessments and an innovative causal modeling approach (coincidence analysis). Methodology. Using VHA data from 2013-2022, we will calculate risk- and reliability-adjusted hospital-level 90-day post-discharge survival after a PerCI hospitalization. Among the 10 highest-and 10-lowest- 90-day post-discharge survival hospitals, we will assess if the organizational factors that are hypothesized to contribute to improved survivorship (e.g., closed ICU units) differ. We will empanel the 10-highest and 10-lowest 90-day post-discharge survival VHA hospitals (N=20) which will be used for the prospective survey collection in Aim 2. Prospective te...