- First, it’s important to take account of the reality that in crisis conditions perfect judgement will rarely be possible. As the WHO Regional Director for Europe put it: “We have to humbly acknowledge that COVID-19 is a fast-evolving situation. We may not always have the best evidence at hand on which to base our decisions, but we do not have the luxury of time to wait until better evidence becomes available.” In short, clinicians and managers will face situations where their best guess is better than no decision at all.
2. The need for fine judgements can be reduced by creating, sharing and using evidence-based guidelines – carefully considered frameworks (like the BMA guidance issued on 03/04/20) and checklists for procedures like receiving, ventilating and discharging patients.
Decisions about how resources are to be allocated in difficult situations must be:
- Reasonable – including based on sound principles.
- Based on the best available evidence and opinion.
- Agreed on in advance where practicable, while recognising that decisions may need to change rapidly.
- Consistent between different professionals as far as possible.
- Communicated openly and transparently.
- Subject to modification and review as the situation develops.
- Step back from the fog. Pressure clouds judgement and increases the heart rate. It is usually possible in the heat of the moment, to step away and give yourself a little more time. Stop – Breathe – Reflect – Choose. The breathing is important – alleviating physical stress responses, and improving our ability to access rational (System 2) processes and reduce unconscious bias.
- Surface the tensions. Difficulty in decision-making often stems from imperfect data or (the near opposite) information overload. Both can mask important underlying issues. Clear thinking is enabled when we can be explicit about what is at stake, and in particular where the source of conflict lies:
- Where is the trade-off between risk and reward?
- How does available time stack up against the speed of action required?
- Is there a clash between ethical and resource considerations?
- Empower your team. Although many decisions rest with you, that does not mean you have to make them alone. Be inclusive. Create the conditions that allow every individual in your team the space and confidence to have a voice. Do not assume that the most senior, most experienced individual in the room has the best plan.
- Prepare to adapt. We are seeing ample proof right now of the military adage that, ‘no plan survives contact with the enemy’. Genuine flexibility is required in the face of constantly changing conditions, and continual evolution in our understanding of what works. This again points to the importance of empowering your team. Michael West has demonstrated the link between compassionate, inclusive leadership and rates of innovation. Strong routines for de-briefing and sharing good practice will foster an adaptive capacity in your team which might save lives.
It is also worth remembering that now more than ever a safety and learning culture is vital. All staff should feel able to raise concerns safely. Local Freedom to Speak Up Guardians will be able to provide guidance for any concerned member of staff. The ultimate test for NHS leaders and managers will be “how will I live with the consequences of this decision?”. In crisis conditions, you will rarely have all the levers at your disposal to deliver a perfect solution. So, your aim should always be to make decisions in good faith, based on the best information you have available at the time – and in line with your values.