Healthcare organizations frequently encounter a predictable pattern when clinical or operational challenges arise. A problem is identified and clinical, operational and frontline leaders develop a proposed solution. Stakeholders generally agree that change is necessary, operational leaders determine that the proposed workflow is feasible, and quality leaders assess its potential to improve safety. The proposal then enters the organizational approval process.
Despite this initial alignment, the proposed intervention may remain unimplemented six months later. One committee requests additional data, another questions whether the proposal conflicts with an existing policy, finance raises staffing and cost concerns, legal recommends revisions, and medical staff leaders question where final authority resides. The initiative stalls because the organization has not clearly established who may make the final decision, whose approval is required, who owns implementation or how disagreements will be resolved.
This pattern reflects a structural decision-making problem rather than a lack of ideas or commitment. Potentially beneficial initiatives lose momentum through repeated meetings, overlapping reviews and ambiguous authority, even when stakeholders broadly agree on the need for change. The risk of delay may increase as organizations become larger and their governance structures more complex.
Decision architecture in healthcare organizations
Decision architecture refers to the formal and informal structure an organization uses to move an issue from discussion to action. It defines who has decision-making authority, who provides input, who implements the decision and how the outcome will be evaluated.
In many health systems, decision architecture has developed incrementally rather than through intentional design. Committees, policies and approval requirements are often added in response to specific organizational needs. Over time, this may produce a structure with numerous opportunities for review but no clearly defined path to a final decision.
McKinsey survey findings showed that only 27% of respondents considered delegated decisions within their organizations to be both high quality and high velocity. McKinsey has also reported that decision-making may consume up to 70% of some executives’ time.
This administrative burden is very relevant in healthcare. The American Hospital Association reported that hospital labor costs reached $839 billion in 2023, accounting for nearly 60% of the average hospital’s expenses. Clinical and administrative time therefore represents a limited and costly organizational resource. Redundant reviews and repetitive meetings consume that resource without necessarily improving the quality of the final decision. More explicit decision pathways may also reduce workplace frustration by clarifying responsibilities and improving organizational follow-through.
Adapting the Decide framework to decision architecture
Kristina Guo, PhD, introduced the Decide model in 2008 as a structured approach to decision-making for healthcare managers. The original model included defining the problem, establishing criteria, considering alternatives, identifying the preferred alternative, developing and implementing a plan, and evaluating the outcome.⁴
Building on that model, the following adaptation applies the Decide sequence to organizational decision architecture, with greater emphasis on authority, consultation, implementation ownership and accountability. Healthcare leaders can use six questions to evaluate how decisions move through their organizations.
Define the decision. Begin with a precise statement of what must be decided. Broad topics may generate discussion but frequently fail to produce action. A clearly framed decision establishes its scope, focuses deliberation and creates a defined endpoint.
Establish authority. Determine where final decision-making authority resides before deliberation begins. Multiple individuals or groups may provide input, but all participants should understand who is authorized to make the final determination.
Consult the appropriate expertise. Identify the clinical, operational, financial, legal and frontline perspectives necessary to make an informed decision. Consultation should improve decision quality without creating unnecessary layers of approval. The ability to provide advice does not necessarily confer decision-making authority.
Identify the implementation owner. Assign responsibility for implementation to one individual or clearly designated team. The implementation plan should include defined milestones, expected timelines and a process for escalating barriers. Without a designated owner, even well-supported decisions may not progress to implementation.
Document accountability. Record the decision, the implementation owner, the expected completion date and the measures that will be used to assess success. A concise decision record may provide greater operational value than lengthy meeting minutes that summarize deliberations without clearly identifying responsibilities or next steps.
Evaluate outcomes. Establish in advance when and how the decision will be reviewed. Evaluation should determine whether the decision was implemented as intended, whether it achieved the expected outcome and whether it should be continued, modified or discontinued. This step closes the decision-making cycle and allows the organization to incorporate findings into future decisions.
Committee function within decision architecture
Committees remain essential in healthcare, particularly when bylaws, accreditation requirements and professional self-governance require formal oversight. Their effectiveness, however, depends on a clearly defined purpose.
A committee may receive information, provide advice, make recommendations, authorize actions or monitor outcomes. Issues arise when members believe they possess decision-making authority despite serving in an advisory role, or when multiple committees review the same proposal without contributing distinct expertise. Overlapping responsibilities can delay action and make accountability difficult to determine.
Committee charters should define each group’s scope, authority, responsibilities and reporting relationships. They should also specify which matters the committee may decide independently, which require further approval and where recommendations must be directed. This structure preserves necessary oversight while reducing repetitive review and improving the reliability of organizational decision-making.
Evaluation of decision-making performance
Health systems routinely evaluate clinical and financial performance but are less likely to measure the performance of their decision-making processes. A focused set of indicators can identify delays, unclear accountability and unnecessary approval requirements:
- Time from formal proposal to final decision
- Percentage of decisions with a named implementation owner
- Percentage of decisions implemented by the agreed-upon date
- Number of approval steps required for each decision
- Frequency with which decisions are reopened because authority or expectations were unclear
The objective is not speed alone. Decisions made without sufficient analysis may create clinical, financial or regulatory risk. The more appropriate objective is decision velocity: reaching and implementing a sound decision within a timeframe proportionate to its complexity and potential consequences.
The adapted Decide framework provides a structured method for clarifying authority, consultation, implementation ownership and accountability. Its value should ultimately be assessed by whether its use reduces decision time, improves implementation reliability and produces measurable organizational outcomes. By strengthening decision architecture, health systems may be better positioned to translate strategy into consistent execution.
Dr. Dalabih is chief medical officer of Corpus Christi, Texas-based Driscoll Health System.
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