Surgical Leadership, Governance, and Quality Improvement: An Organizational Analysis of Nigerian Teaching Hospital Surgery Departments

Leadership quality and governance structures within surgical departments are determinants of clinical outcomes, staff wellbeing, and institutional performance, yet these organizational dimensions of surgery in Nigerian teaching hospitals have received no systematic scholarly attention. This dissertation conducts an in-depth organizational analysis of surgical leadership, governance practices, and quality improvement systems across 10 teaching hospital surgery departments representing all six geopolitical zones of Nigeria. A qualitative organizational case study design was employed, combining document analysis, 90 semi-structured interviews with surgical consultants, residents, nurses, and hospital administrators, and observation of departmental meetings and audit processes over an 18-month period from 2022 to 2023. Analysis was guided by Leadership Practice Inventory frameworks and organizational governance theory. Departmental leadership was predominantly hierarchical and consultant-dominated, with limited resident or nursing voice. Formal surgical audit processes were absent in six of 10 departments. Quality improvement initiatives were personality-driven rather than system-embedded, leading to non-sustainability. Cross-departmental collaboration for complex cases was rare, and conflict resolution mechanisms were poorly defined. An original Surgical Departmental Governance Framework, comprising eight evidence-based organizational standards, is proposed as the primary theoretical contribution. The study recommends mandatory surgical governance training for department heads, residency program accreditation standards incorporating departmental culture requirements, and national surgical quality improvement incentive programs. Keywords: surgical leadership, governance, quality improvement, Nigeria, organizational analysis