Management as the art of politics.

This discussion has furnished a personal view of some of the features involved in managing a busy surgical ICU. Experience has provided the reference frame rather than an extensive literature search and associated bibliography. Physician involvement in ICU management depends on the character of the institution and the ability of the director to influence physician, nursing, and ancillary staff behavior by force of personality rather than by relying on universally accepted behavioral covenants. The issues raised are controversial and should provoke more discussion than acceptance. It is to be hoped, however, that some of the points will be recognized as common problems requiring solution in all similar environments. "Management as the art of politics" summarizes the 1980s' approach to ICU governance, and it is fitting to question its acceptability in an era of cost containment, resource restriction, and increased awareness of the rights of a patient and his or her family to control the extent of medical care rendered. Laissez faire management is unacceptable today, and future governance will reflect increased responsibility for unit managers and the realization that the ICU is an institutional and societal resource that cannot respond to the prerogative of individual users. The Magna Carta of ICU governance remains to be written. It is inappropriate for ICU managers to assume responsibilities that preclude the prerogative of the admitting physician and appropriate medical consultants. It is equally important, however, that the medical community recognizes the importance of adjudicating access to and care within ICUs. Scarce medical resources used in these areas represent as much as 20% of all medical expenditures, the bulk of which is spent in unsuccessful ventures. Management of this resource cannot be relegated to inexperienced, naive, or self-serving clinicians. The tools for managing the ICU in the '90s have been introduced, and they will begin to define the new concept of a successful outcome following admission. Clinicians traditionally have focused on individual patients, and this approach has led to many improvements in care. The next challenge facing the ICU management team will be to organize the process of patient care that will ensure the best possible individual outcome while promoting general efficiency of the available resources to function for all. Physician and nurse managers will be co-responsible for adjudicating a complex, costly, and vital hospital resource; the price of failure is unacceptable.(ABSTRACT TRUNCATED AT 400 WORDS)