Critical Decisions And Complex Patients: Dr. Raymond Rupert

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If a healthcare organization does not properly identify and manage their critical decisions, then this can lead to big problems for everyone.

Here is a case study:

A 65 year old patient was found to have a large mass near the bottom of his esophagus (food tube). At the same time, it was discovered that he had aortic stenosis ( a tight aortic valve). Because of the aortic stenosis, the operation to remove the esophageal mass was delayed.

About five months later, the cardiologists finally made a decision that the surgeons could operate. Unfortunately, it was too late because the esophageal mass had become inoperable.

This hospital needs an immediate solution for the unacceptable delays with critical decisions. They fail to stratify decisions into critical and non-critical. They don’t use a decision hierarchy.

There is an imperative for this hospital to improve their decision processes and their decision architecture.

They should start by developing a work flow that clearly articulates which decisions are critical and non-critical. They should set up a process that includes a deadline for each critical decision. Timelines help!

They should map the steps taken with their decision making for both critical and non-critical decisions. It is important to identify those elements that block effective decision making and to streamline the process. And they need to establish measures to track decision effectiveness to answer the question about whether they are good or bad decision makers.

A focus on decision effectiveness can help to transform the organization’s culture. The focus must be on defining what decisions need to be made, who will play a role in making the decisions, when will the decisions be made and what kind of processes will be used to make the decisions.

Here are some key points for improving decision effectiveness:

Deadlines are essential to avoid the trap of decision drift.

Collaborative decision making is effective in producing faster and higher quality decisions.

It is important to separate the discussion of the relevant issues and choices from the decision making.

Not all decisions should get equal time and attention.

Decide which decisions are critical.

Decide who will have the power to make these critical decisions.

The goal is to improve decision effectiveness for critical decisions in order to get better patient outcomes. That is our focus at Rupert Case Management. Our job involves focusing on the critical decisions and assisting with the decision process.

We will often set up an “virtual advisory board” for our clients to assist in making the best possible decisions.¬† If there is still confusion about a decision, then we will ask an outside expert to assist in making a “meta decision”.

Research presented in “Decide and Deliver” by Blenko, Mankins and Rogers of Bain & Company, Harvard Business School Publishing¬† 2010 ( page 153) found that organizations with excellent decision effectiveness made 38% better decisions (quality), made them 37% faster (speed) and executed them 38% more effectively (yield) and were 2.7 times more likely to use the right amount of effort in the process.

In fact, organizations that made the fastest decisions were 4.2 times as likely to make the best decisions and organizations that made the best decisions were 8.2 times as likely to excel at execution compared to their peers.


Improving the decision architecture and decision work flows for critical decisions really matters for our clients with complex health problems. Now you know!