Within the past several years, critical care leaders at academic medical centers and large community hospitals have increasingly examined their ICU infrastructure and clinical staff and take on “battles” to pull the ICUs away from departments and place them into a hospital-based environment and political and administrative infrastructure. From the hospital’s perspective, a critical care organization (CCO) offers an excellent opportunity to bring together all ICUs under one leadership with defined accountability. Added advantages include improved opportunities to contain costs; implementation of local and national patient safety and quality initiatives through protocols, standardization of technologies across ICUs with resultant savings from volume-based equipment and supply purchases, warranties, and staff training; enhanced critical care research; and improved recruitment or retention of faculty through a more stable environment.7 We recently reported a descriptive multicenter study on the structure, governance, and experience to date of CCOs in hospitals in North American academic medical centers.7 We identified very few CCOs (n = 27). Of the 27 CCO physician directors from 23 institutions (19 sites in the United States and 4 in Canada), 24 (89%) completed the survey. Nearly 80% of the CCOs were created in the last 15 years. Majority of these CCOs were located in larger urban hospitals (> 500 beds) and 79% were primary university medical centers. The transition to a CCO was initiated by the hospital administration in 46% and/or existing critical care service or division in 42% and by consensus of department chairmen in 13%. There were various models of CCM governance, reporting structures, hospital support, and general satisfaction. Almost 90% indicated that their CCO governance structure was either moderately or highly effective, and are still evolving. On average, there were 6 ICUs per hospital with an average of 4 ICUs under CCO governance. In-house intensivists were present 24/7 in 49%, nonphysician advanced practice providers (nurse practitioners, physician assistants) in 63%, hospitalists in 21%, and telemedicine coverage in 14%. Nearly 60% indicated that they had a separate hospital budget to support data management and reporting, oversight of all ICUs, and rapid response teams. We attributed the relatively small number of CCOs that currently exist to several factors including, perhaps, the reluctance of department chairpersons to give their ICUs up to a CCO as they perceive potential loss of billing, triage, and patient and staffing control. Furthermore, CCM has been very intertwined with other disciplines in terms of fellowship training and attending staffs (ie, medicine, pulmonary, anesthesiology, surgery, neurosciences, and pediatrics) due to the absence of a unified critical care fellowship track and certification examination. Thus existing departments have come to believe that their ICUs and intensivists especially in specialty ICUs have little in common with each other. Finally, very few CCM graduates have the necessary skill set to champion the creation and lead CCOs despite CCM fellowship program training in management and team leadership.7