How Leaders Make Decisions During Times of Crisis

By Thomas K. Varghese Jr., MD, MS

April 24, 2020

There comes a time in every leader’s job where a crisis emerges. In the Oxford English dictionary, the word “crisis” is defined as “a time of great danger, difficulty, or confusion when problems must be solved or important decisions must be made.”

Two aspects are thus clearly spelled out: the gravity of the situation and the need to make decisions. In health care, when a crisis occurs, lives are at stake. But how does a leader make these decisions? Even better, how does a leader make the right decisions in a world with constantly changing information and where the decisions often need to be made with incomplete information?

On March 11, 2020, the World Health Organization declared that COVID-19 was a pandemic. At the time of this article, there had been nearly 2.5 million confirmed cases worldwide and 170,000 deaths from the disease. The first ever pandemic caused by a coronavirus has caused chaos and devastation across the globe, and its impact will be felt long after the pandemic comes to a close. 

The goal of this article is to detail some important steps in the decision-making process, with the current pandemic as a backdrop. The lessons learned, however, are applicable to any crisis situation, with the hope that we may remember them in the post-COVID-19 world. 

1. The well-informed leader makes well-informed decisions
In order to make an informed decision, timely and accurate information is of utmost importance. To do this, you need the right team members, metrics, and communications strategies.

The Right Team Members
In sports, we often hear about the value of an “all-rounder,” a person who is generally good at a wide range of things, skilled in many different areas. There is a big difference between versatility and levels of excellence. It is impossible for a human being to be at the highest level of excellence in every single category. That’s why you need a team. 

In order to create the environment where you can make informed decisions, you need the right team members. Hence, the first decision in any crisis is to take stock of your existing teams. 

Are all the needed content experts present so that you can make informed decisions? Are existing teams well-equipped to do the job at hand or do you need to assemble new taskforces/teams/workgroups? Team members need to represent critical disciplines and be empowered to complete needed action items.

The Right Metrics
After assembling your team and working out the meeting logistics, the next critical step is focusing on the right metrics. A metric that can’t be acted upon is often meaningless. What can help is remembering the overall mission of the organization. Every mission statement for a hospital system across the nation has some form of the following words: improving the health status of the community. Who makes up your community? What is the health status of your community? For COVID-19, what is the number of infected patients in your community? How many have required hospitalizations and what level of care is needed? 

By defining core metrics, you can then figure out what pieces of data are missing and what steps are needed to find the missing data. For COVID-19 status, this is why testing and the ability to test are critical pieces in your system planning and response. If you don’t have this information, you will not be able to make informed decisions. 

By defining core metrics, you can then figure out what pieces of data are missing and what steps are needed to find the missing data.

The Right Communications Strategies
In the age of information overload and global data at the tips of our fingertips, it is amazing how many “experts” emerge all around us. I use the word experts in quotation marks to signify the fallacy of the statement. Dr. Google is not just a patient phenomenon. 

In the modern era, the key for communication strategies during a crisis is two-fold: having a central source of communication (sharing of evidence-based knowledge) and, sadly, a mechanism for rumor control. You need to communicate your steps in action and then be vigilant about the emergence of rumors around us. 

At the University of Utah, we suspended performance of elective surgical procedures throughout the health system on March 16, 2020. We shared transparently with all of our stakeholders the rationale behind the severe action and the planning of next steps in the process. We centralized the communication of ongoing efforts through a shared internal website and provided timely delivery of action steps through emails that were vetted and signed by Command Center groups. Every step in the communication process was deliberate. Definitions of elective, urgent/emergent, and time-sensitive procedures were outlined with the guidance of content experts and national guidelines. 

Before enacting rules such as a zero visitors policy, universal masking of all employees and temperature screenings of every human walking into our buildings, there was robust debate, deliberation, and consensus on both the policies and procedures. We enacted (initially daily and now biweekly) web livestreams of leaders presenting the data, sharing what was known and not known, and clearly explaining the rationale and need for policies and procedures. This was an organized, effective system-wide team effort. 

2. A leader never forgets the lives s/he impacts
Many a decision will need to be made looking at the cold, hard facts. But we have to remember that every metric reflects a life. A death rate is a summary of lives lost. A salary cut represents reduced wages for those sacrificing and doing their all for an organization. This doesn’t make the decisions easier to make. But it humanizes the decision-process, allowing leaders the opportunity to prioritize where decisions have to be made. 

3. “I’ll go first.”
James Mwizerwa is the Environmental Services (EVS) Discharge Team Supervisor at the University of Utah Hospital and is in charge of 45 people who clean it. There was understandable fear when COVID-19 first emerged. Even though a recent news report detailed the steps our EVS team took, it was a comment that James made to all of us during a command center meeting that resonated: “I’ll go first.” No matter what action needed to be done for proper disinfection, cleanliness, and prevention of infection, James made sure to become knowledgeable about the evidence behind the best practices in infection control and set the example by being on the frontlines, volunteering to go first. He raised the bar for all of us. I know that all of my surgical colleagues would do the same without hesitation.

A leader remembers the important things in life. In my opinion, s/he sets the standard in all that s/he does. A true leader is not a title, and leadership roles should not be token career-recognition awards. A leader goes first, sets the example. 

If universal masking is your policy, a leader needs to model that behavior. If pay cuts are needed in an organization, the largest cut should be for the leader. If you want your team members rested for the long haul, you need to intermittently take some time off once things have stabilized, and trust your team. Set the example. “I’ll go first.” 

A true leader is not a title, and leadership roles should not be token career-recognition awards. A leader goes first, sets the example. 

4. Human beings are human beings 
Human beings are social; they don’t do well in isolation or with endless inaction. 

You will encounter three groups of people initially in a crisis. One group will want to enact a whole bunch of things right away and are impatient with deliberation. Another group will not want to do anything unless the highest levels of evidence are present for every single step of the way. A third group will become emotional and not be able to function. With ever-changing information from the frontlines during a crisis, a single person can go in and out of all three groups within a single day.

Expect these reactions. It’s understandable. Everyone in health care has at their core a willingness to help others in need. Remind yourself of this. Give others the benefit of the doubt. Fear drives emotions. And sometimes the emotions are in you. Learn to recognize them. Learn to manage them in times of need. 

In the ideal world, one would like to make a decision only after all of the meaningful and complete information is at hand. This world does not exist. Inaction in a health care crisis will lead to lives lost. Making decisions in a crisis with incomplete information is the norm and will feel unnatural. 

We as leaders need to be brutally honest as to what is known and unknown. Bringing in a timeline helps set expectations, but realize that the timeline will need to be modified, especially with the changing effectiveness of flattening the curve in a pandemic. However, even a changing timeline is better than none. Zero activity for an unknown period of time is not a realistic option. 

It helps to strategize with your local content experts and setting up reliable communication efforts with other organizations facing a similar situation.

5. “Teaming is a verb”
Dr. Amy Edmonson, professor of leadership at Harvard Business School, brilliantly introduced the concepts of psychological safety and teaming to the literature: “Teaming is a verb. It is a dynamic activity, not a bounded, static entity. It is largely determined by the mindset and practices of teamwork, not by the design and structures of effective teams. Teaming is teamwork on the fly.”

You will note that this article doesn’t focus on any specific action or team structure, but on processes and practices. This is intentional and allows for flexibility. You need to take into account your local environment, content expertise, and team experience. It allows for team members to speak up, ask questions, and actively participate in the decision-making process. 

In a crisis, leadership is not confined to those with official titles. You will find yourselves functioning in new roles; opportunities for effective leadership are plenty. The pandemic has revealed deficiencies in traditional hierarchy, and our hope is that those who have stepped up will have the opportunities to continue to do so after this crisis. 

Decisions are often challenging and typically made with incomplete information. Assembling the right team members, remembering your mission and core principles, and teamwork on the fly are keys for leader to make effective decisions in crises. 

You are a leader. Go forth and change the world for the better.  


Connect with Dr. Varghese @TomVargheseJr 

Dr. Varghese is the Executive Medical Director and Chief Value Officer at the Huntsman Cancer Institute at the University of Utah, Head of the Section of General Thoracic Surgery and Program Director of the Cardiothoracic Surgery Residency. He is the Deputy Editor of Digital Media and Digital Scholarship of the Annals of Thoracic Surgery, and holds leadership positions in The Society of Thoracic Surgeons, American College of Surgeons, the Thoracic Surgery Directors Association, the Society of University Surgeons, and the National Cancer Care Network (NCCN). 

The opinions expressed in this article are those of the author and do not necessarily reflect the views of The Society of Thoracic Surgeons.