A surgical department is like a complex organism, and to function properly and at maximum efficiency, each and every sub-component of the department must function correctly. As well the interrelationships within and between these sub-components must be smooth and free flowing. And finally relationships with external factors must also be appropriate. Anything less than optimization of any of these 'systems' will result in a surgical department with various degrees of dysfunctionalism.

A surgical department is dynamic at all times. This includes personnel, procedures, physical layouts, the many regulations (both in house and governmental), not mention a myriad of other ever changing factors that affect the overall function of the department. The result of course is that to achieve the acme of functionality may be impossible on an ongoing basis but benchmarks can be set and 'gold standards' can be aimed for.

In some surgical departments most aspects are in good shape and only a little fine tuning, without ruffling feathers (surgical department personnel are notoriously egotistic for some reason) is necessary to reach the next level of functionality. In other departments, the dysfunctionalism is so overt and rampant, that only a major revision of the whole department will restore any significant degree of efficiency and functionality. Most surgical departments lie somewhere in between and to the disinterested it may appear that the department as a whole is not being run properly. On the other hand an in depth study may show that over all the department is being run as well as possible considering the circumstances but that only one sub-component is at fault and asynchronous with the efforts being out by the other sub-components. The goal therefore is to identify this sub-component and once identified and defined, devise a plan of 'change.'

In my experience as an active practicing consulting surgeon over the last 25 years with extensive experience in administrative medical positions as well, I have often found myself searching for the true cause of any dysfuntionalism. Often I have been surprised at how a very minor problem has resulted in a major loss of efficiency and productivity and whether the problem was personal, interpersonal, physical, or regulational, once identified, proved to be easily and simply corrected.

Over the years I have also noted that seldom is an obstacle to efficiency inserted into the system primarily to be an obstacle. It is more often associated with an entirely different agenda that may have nothing to do with the goal at hand, a smooth and well run surgical department that is reaching for the 'gold standard' in productivity. Once this separate agenda is identified and defined, a rational approach can be used to alter or if necessary eliminate it from the sub-system and without any major changes a significant improvement in overall output results.

Many surgical departments have historical traditions based on geographic locations, physical characteristics of the plant, patient pool, department non-medical and medical personnel, as well as professional (surgeons and physicians) personnel. These traditions may be recent but in many situations they go back many years, some for a whole generation or more. These long time traditions which in many instances may have become obstacles to improved function, may not be apparent to the involved parties who are so close to the situation and have been so for so long. Even more to the point, these 'traditions' may be so ingrained that 'change' or the thought of change is anathema. This is where an outside and 'disinterested' observer is necessary. Someone who is not associated with the traditions and histories of the particular surgical department and can thus make an impartial assessment of the situation at hand, unencumbered and with no personal agendas.

Of course once the causative factor or factors of dysfunctionalism are identified and defined the next step is do develop an appropriate remedial action often defined as change. To effect any sort of change successfully total cooperation from all involved parties is mandatory. To garner this degree of cooperation it is essential that all persons involved with, or that will affected by, any change fully understand the reasoning behind the necessity for the change and are prepared to come aboard. Until this level of understanding and cooperation is achieved any attempt at successful remedial action will be doomed to failure or at best to only a modicum degree of success, hampered by many an unhappy or resentful person.

Dysfuntionalism in a surgical department may be overt or covert. It may be obvious or subtle. Whatever, the result will be a loss of potential efficiency and thus productivity, and in today's competitive environment the end result may be a very serious long term effect on the viability of a health care facility as a whole.

The following questions should be asked by anyone in a responsible position:
- Is our surgical department producing optimally?
- What are the benchmarks?
- What is the gold standard?
- Is there any dysfunctionalism?
- Can the causative factors be isolated and defined?
- Can we effect change?
- Do we need external direction?
- How long can we wait?

Change is a thought that sends shudders to one degree or another down the spine of most persons and especially so to persons involved with hospital surgical departments. Many such departments are riveted to the past with an intensity, that without outside insight and direction they will remain mired in the past until it is to late to effect any successful change.