Health care reform, public concern, and managed care will create an environment that demands highly creative strategies to deliver quality care while reducing costs. Patient satisfaction and outcomes will take on a high priority. To meet this challenge, the neurosurgical ICU of the future will be designed with a patient-focused theme wherein the physical environment embodies healing and humanism. Services will be brought to the patient rather than the patient accommodating the system. Patients and families will be the directors of their own care. Staff and families will have access to a highly sophisticated clinical information system, and learning for staff at all levels will be a part of everyday life in the ICU. Unit management will be within a framework of shared governance wherein the power base is with the direct care givers, and decision and policy making happens at the point closest to the patient. Patient outcomes will be a result of a highly organized collaborative model that includes primary nursing, critical paths, and case management. Partnerships between nurses and unit support staff will create skill-mix changes that allow the nurse to spend less time on nonclinical unit maintenance-type functions and more time with the patient and family. This will have a positive fiscal impact as well as enhance patient satisfaction and outcomes.