It may be true, as Heraclitus said, that change is the only constant, but the pace of change is variable. The current environment is one of exceptionally rapid and momentous change. A key lesson from the COVID-19 pandemic has been the importance of agility for organizations of all sizes. For large healthcare organizations, which tend to be relatively change-averse and less than nimble, this has created unease and dissatisfaction with the speed and quality of decisions affecting both current and future operations.
What gets in the way of rapid and effective decisions? Often, it is lack of clarity about how the decision is to be made. For important decisions, especially in large or complex settings, it is most helpful to have an explicit framework to guide the process. One that I have found useful is described by the acronym DRIVE.
Decision. What exactly is being decided? Who has the ultimate authority to make the decision? Is it an individual or a group, and if a group, how will the decision be made – consensus, majority vote, etc.? Are there any parameters that will define limits on the decision (e.g., budget, regulatory considerations)?
Recommendation. Often the decision will be to accept or reject a recommendation, or choosing one of several recommendations. Who will be charged with making the recommendation and presenting it to the decision maker? (For a relatively straightforward issue, the recommendation is likely to be made by the decision-maker themselves.) What is the timeframe for developing the recommendation? Since the drafting of a plan (or several plan options) is a creative process, the recommending body should have the right expertise to inform the product, but be small enough that the work is not slowed down. The recommendation should include a summary of the input provided (see below), and it may be helpful to have someone play the role of “devil’s advocate” to ensure that the full range of input is considered.
Input. This may be the most critical element to define. Whose input will be sought as the recommendation is developed and the decision ultimately made? This group can and should be broader than the one drafting the recommendation, and should be able to reflect the perspectives of all key stakeholders, as well as the appropriate content expertise. On the other hand, it need not be exhaustive; those providing input should be able to speak on behalf of individuals or areas other than their own. For example, a decision regarding changes in the operating suite should be informed by input from both employed and independent surgeons, as well as those who do primarily inpatient vs. outpatient cases, but not necessarily every single surgeon on staff. Explicitly identifying what input is being sought and from whom will help avoid information gaps during the process, while heading off complaints about missing perspectives from people who may disagree with the ultimate decision.
Those whose input is sought need to understand their role, which is to provide information that may be relevant to a decision that has yet to be made. While not every piece of input will be incorporated into a decision, every piece of input should have the potential to influence that decision. If the recommendation is already finalized or the decision made, seeking additional “input” would be disingenuous.
Vetting. The development of the recommendation is often an iterative process. After an initial round of input, a draft recommendation is developed, and can be refined based on additional rounds of input. Once the recommendation is final (or close to it), it is often useful to vet it with another group of stakeholders before the decision is made. This could include a subset of those who provided the earlier input, or others not previously involved may be brought in. The purpose of this vetting is twofold. The first is to prepare the recommendation to be brought forward to the decision-maker for action. It provides a final opportunity to ensure that no important perspectives were omitted, and to gauge reaction from key stakeholders. If there are any whose assent will be critical, this is a good time to solidify that. The second purpose is to start to get thoughts on how the decision will be communicated, and to identify key execution risks that need to be considered.
Execution. Any decision is only as good as its execution. Who will be responsible for carrying out the decision? What key dependencies are there? What risks have been identified, and what are the plans for mitigating them? How will the progress be monitored?
While this degree of planning and specification may seem like overkill, it has several important advantages. First, while we cannot eliminate all the sources of bias that come into play when human judgment is involved, a rigorously defined process can help minimize their effect. Second, as mentioned above, laying out the process including who was involved at each step can aid in obtaining buy-in from those who may not agree completely with the decision. Finally, having a process greatly facilitates delegation of decision-making. Once the delegator and the delegee have agreed on the various steps, the latter should be empowered to proceed without fear of being second-guessed on how they came to their decision.
Here is an example I recently went through. Due to truly unprecedented summer patient volumes, and pandemic-related staff turnover, we were facing staffing challenges for many roles in various parts of the organization. Several executives were developing plans for the workforce in their area, but a consistent, organization-wide approach was needed, and quickly. Here was the process:
D. The COO would be the ultimate decision-maker on a plan to add staff in all patient-facing roles where we had identified shortages, with immediate, short-, and long-term components. As long as the plan was consistent with our contract obligations, and it did not put us significantly at risk for failing to meet our financial goal of break-even for the year, she could make the decision without my approval.
R. The recommendation would be drafted by a subset of the executive leadership team (COO, CFO, CNO, CHRO), to be ready for a final decision by the COO within 5 days.
I. In addition to the recommending group, input would be obtained from labor relations, senior director of talent strategy, nursing leaders, legal, finance, and the equity and inclusion team.
V. Draft recommendation would be vetted with the full executive leadership team (me and my direct reports).
E. Execution would be org-wide, with particular involvement by the HR team. Key measures of progress and success would be a decrease in critical staffing shortages, new hires (including position fill rates, time to fill, and workforce diversity), and budget variances.
With this clarity, those involved had their marching orders, and a plan was developed and a decision made within a week – practically warp speed for us! There was widespread buy-in from HR, front-line managers, and the unions, and based on anecdotal information obtained during rounding, appreciation from front-line staff that the senior team was addressing their primary source of stress.