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One of the major changes which
has occurred in hospital governance has been a
move towards a corporate or semi corporate structure.
The resident should understand the general outline
of reporting systems in each hospital as they
differ, according to the state of development
of the hospital. The prime concern of the resident
is with patient care, research and teaching but
residents must also acquire management skills
during the training program. The prime responsibility
of the resident is the management of neurosurgical
health care delivery at that institution and as
senior resident status is achieved, the resident
should become more interested in and aware of
major management issues within the hospital. Considerable
literature exists on such topics as conflict resolution,
intergroup relationships, goal setting and strategic
planning, and incentive and disincentive programs.
Unless the resident understands these issues,
he or she will not be an effective chief resident
or staff neurosurgeon. Many of the technical issues
can be distilled into a combination of common
sense and good manners.
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Nursing
In recent years the management
structure of nursing has rapidly evolved. The
nursing profession now has stated unique objectives
and nurses see themselves as having a particular
niche in health care delivery. Nurses are colleagues
of equal status and importance to the medical
profession. Residents should, therefore, relate
to members of the nursing profession as members
of one profession relating to members of another
profession, albeit a profession with very similar
goals. Job dissatisfaction in the nursing profession
is currently very high and a significant shortfall
of nurses is noted in the very areas which affect
neurosurgery. Residents should go out of their
way to try and enhance job satisfaction amongst
their nursing colleagues and at all costs must
avoid rudeness, lack of courtesy and bad manners.
It is appropriate for residents to have a good
understanding of the hierarchical reporting system
of the nursing management team in their institution.
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Cost and Quality Control
The single most important environmental
factor affecting neurosurgery in the next decade
will be that of cost control. At present, it is
extremely difficult for residents to be part of
effective cost control because information systems
are, in most instances, at an immature state of
development. Nevertheless, a common sense approach
indicates that every possible avenue of ambulatory
treatment should be explored so that only those
patients for whom in hospital care is essential,
are admitted. More and more attention will be
given to quality of care. This concept embraces
a spectrum of measurements. At one extreme there
is the "hotel" component which involves
such concepts as cleanliness, service to patients,
appointment scheduling, etc. In this area is included
the physical appearance of the resident in terms
of appropriate personal appearance and dress and
the concern and compassion expressed by the resident
to patients and their families during their hospital
stay. At the other end of the spectrum is the
question of morbidity and mortality and outcome
measurement of surgical procedures. Residents
must adopt a continuous questioning attitude in
these areas. The scientific method of evaluation
of the efficacy of surgical procedures is being
greatly developed and implemented in the current
era.
Society will rapidly demand
evidence of efficacy of surgical procedures as
a key component of cost control. Modern residents
brought up in a scientific era usually have little
problem coping with these concepts. The day of
the arrogant surgeon proclaiming "facts"
based on personal biased experiences is over and
the day of scientific inquiry with appropriate
trial design is at hand. Take the hint and prepare
yourself thoroughly for an era of both cost and
quality accountability.
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Introduction
