Mastering the Decision-Making Process Before Disaster Strikes

Imagine your hospital has lost primary power due to flooding from a rainstorm which has been raging for five days. Water is leaking into your basement where your backup generators and fuel pumps are located. Engineering thinks the hospital can remain operational for an additional twelve hours if the rain stops soon. Unfortunately, weather forecasters predict at least two more days of rain. Decisions need to be made – and fast! Do you evacuate the facility? What reinforcements are needed to defend-in-place? How can you prevent the basement from flooding further? What are your alternatives?

Challenging Decisions Demand More Consideration

Hospital leaders make decisions everyday that are so routine that they are often made without giving them much thought. On the other hand, according to, difficult or challenging decisions demand more consideration because they involve:

  • Uncertainty – Many of the facts may be unknown or difficult to verify.
  • Complexity – There can be many, interrelated factors to consider.
  • High-risk consequences – The impact of the decision may be significant.
  • Alternatives – There may be various alternatives, each with its own set of uncertainties and consequences.
  • Interpersonal issues – One needs to predict how different people will react.

When making a complex decision, such as the need to partially or completely evacuate a healthcare facility, leadership needs to engage a decision-making process that incorporates problem-solving, data acquisition, and risk quantification. Threats to patients and staff must be considered. Predictions need to be made and quantified about changing weather patterns, availability of transportation assets, stability of utilities and communication systems, and access to trained and available emergency response resources. In many cases, too much information can be as daunting as insufficient intelligence. Even experienced emergency management professionals and hospital leaders become anxious and mentally exhausted when confronted with the need to make such difficult decisions. These feelings commonly arise regardless of the amount of data available.

Starting the Decision Making Process

The decision-making process starts by asking the first and most important question, “When is the decision or resolution needed?” If the decision is required in minutes to a few hours, then it is often made without the knowledge that could have enabled a more informed choice geared toward reducing risk. Too much time and the benefits from the alternative solutions are delayed.

Failure to make a decision in a timely manner reduces the options that remain. In the case of evacuation, for example, evacuating too soon may place patients and staff needlessly at risk if the potential threat does not materialize. Evacuating at the same time as the general public may increase the risk to patients’ health and safety if traffic congestion and other road complications increase travel time. Finally, evacuating too late increases risk if patients do not arrive at their destination before a storm or hazard strikes.

Common Decision-Making Errors

Unfortunately, during times of stress and uncertainty, when action needs to be made quickly, a number of common decision-making errors occur:

  • Shooting from the hip – Making impulsive decisions without adequate information.
  • Planning fallacy – Biases creep toward underestimating how long actions take.
  • Primacy effect – Tendency to weigh initial events more than latter events, promoting a quicker decision.
  • Immediate gratification – People tend to prefer immediate versus delayed decisions.
  • Neglect of risk – Inclination to completely disregard probability of risk when making uncertain decisions.
  • Herd instinct – A common bias that adopts the views and follows the behaviors of the majority.
  • Short-sighted shortcuts – Relying too heavily on convenient facts or easily obtained information.

Objectively Evaluating Alternative Solutions

A good decision-making process enables objective evaluation of alternative solutions by gaining sufficient knowledge of these options in order make a reasonable selection. In this manner, uncertainty is reduced but never eliminated. In the case of evacuation, there are several alternative options to consider including defend-in-place, localized relocation or partial evacuation, creation of a buffer zone, adding resources, and establishing alterations in the standard of care.

Seven Steps to Effective Decision Making

According to scholars at the University of Massachusetts Dartmouth, decision-making is the process of making choices by setting goals, gathering information, and assessing alternative options. Their seven-step process in effective decision-making includes:

Step 1: Identify the decision to be made. Does the hospital need to make a partial or complete evacuation, or can it shelter-in-place?

Step 2: Gather relevant information. When will utilities be reestablished? How long can we run our backup generators? How much fuel do we have on hand? Are there other hospitals in the area available to accept our patients? Do we have access to sandbags to barricade around the hospital? What is the current capacity of EMS to transport our patients? What government resources are available?

Step 3: Identify alternatives. In this step, it is important to list all possible and desirable alternatives. Many such alternatives to evacuation are listed above.

Step 4: Weigh evidence. In this step, you draw on your information and gestalt to imagine what it would be like if you carried each alternative to the end. You must evaluate whether the need identified in Step 1 would be helped or solved through the use of each alternative.

Step 5: Choose among alternatives. Once you have weighed all the evidence, you are ready to select the alternative or combination of alternatives that seems best suited to you.

Step 6: Take action. You now take some positive action that begins to implement the alternative(s) you selected.

Step 7: Review decision and consequences. In this last step, you experience the results of your decision and evaluate whether it solved the need you identified in Step 1. If resolution occurred, you may stay with this decision for some period of time. If not, you may repeat certain steps in the process to make a new decision.

When the complex environment of healthcare intersects with the multifaceted challenges associated with emergencies and disasters, hospital leaders will be called upon to make key decisions and take actions that may go against their instincts. They will need to know how and when to gain knowledge, evaluate and weigh options, share power, take the lead, and look to the wisdom of the group. A deep understanding of the decision-making process combined with the ability to embrace complexity and risk, and the willingness to remain flexible will be required of leaders who need to make important decisions in times of uncertainty. As the best-selling author and philanthropist Tony Robbins said, “stay committed to your decisions but stay flexible in your approach.”


Smarter Faster Better: The Secrets of Being Productive in Life and Business by Charles Duhigg, March 8, 2016.