How to Encourage Decentralized Decision Making; With Guardrails

Decentralized decision making.

Prior to 2013, Confluence Health was two separate organizations that were micro-managed by executive teams (approximatley 2,500 total employees).  After merging organzations, we’ve grown significantly (approximatly 4,000 employees) and it’s impossible for a small executive team to micro-manage the organization.  What strategies have others used to help push decision making down to a service-line / department level but also maintain guardrails that help ensure the sum of these decisions isn’t harmful to the organization.  A few years ago we allowed service lines and departments to make staffing decisions and the organization started struggling financially becuase of excessive FTE adds.


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Participant comments on How to Encourage Decentralized Decision Making; With Guardrails

  1. I think it is highly important to push decision making to service lines as much as possible. They are the ones who (should) know best what the patients’ need are, how the processes are working and how to improve them. However, making them capable of making the decision requires that you train them to do that. You have to engage them so that they understand what the values, vision, strategy, and goals of you organization are and how those impact on what their goals at the service line level are. This takes quite a bit of work and time. Once you have agreed with them on their goals and KPIs, you should start allowing them some freedom to try things and take decisions in order to achieve their goals. However, you should also set them clear boundaries within which their decisions must be and limits when they must reach for their superiors. You should follow their progress closely and coach and guide them in their process. Empowering the service line level and making them capable and accountable for decision making takes time.

  2. Front line team members should have decision making contribution to work flow and process improvement. I also believe that decision making about staffing/FTEs, etc should be pushed down to the lowest possible level, but with any authority comes accountability. it seems like maybe there wasn’t clear expectations around productively, etc. and associated accountability.

  3. I agree with the above comments around making front line teams and middle managers key contributors to the organizational decision making apparatus. The current model is not sustainable, as you mentioned in your post, and if continued will probably lead to negative impacts, the biggest being that senior leaders will be to wrapped up in operations that they will fail to due their due diligence in strategic planning and development. One initial thought is that organization might want to look at its investment in developing front line leaders. What programs has the institution created that will help shape/mold the front line leadership skills that they are looking for? This should be a key first priority for the team.

  4. Our organization has created division strategy units. These units are led by a physician leader. They receive support from a designated senior leader, project manager and small resource team. The senior leader at the table helps ensure that the unit is headed in a direction that is congruent with the larger strategy of the organization. Specific division goals and initiatives, however, are created within the unit. Monthly report backs to the organization senior leader team are conducted. A lot of ownership and very actionable tactics has already been produced by this new infrastructure.

  5. We also struggle with empowerment and ownership. I would first make sure there are clear hospital-wide goals and then create a goal cascade, allowing each division or unit to create their own specific goals that roll up to the hospital goals. The tactics to achieve those goals should be created by the frontline staff. I would also make sure to celebrate successes, but also teach leaders how to “fail well”. Senior leadership needs to create a safe environment for leaders to acknowledge failure and teach them the skills to transform a failure to an opportunity. One way to create this culture is to hold frequent debriefs. During a debrief you discuss what went well, what didn’t go well, and what you would change next time. Debriefs can be held after meetings, go-lives, clinical events, etc. This helps to install a culture of reflection.

  6. I agree wholeheartedly with the above comments regarding the need for front line decision making at the service line level. These best know the business needs, but in order to make the best decisions it requires ensuring that they have the knowledge and resources available to make the best business decisions. Operational and financial performance metrics have to be a key part of the accountability process with periodic assessment with the executive teams. These teams need to understand the overall goals and expectations, but importantly need to also know the “do not do” (at least not without further discussion) list.

  7. Decision-making and autonomy at the service line level is the best way to foster employee engagement and satisfaction, along with clear metrics/expectations/targets. Continuous support from upper management must be available as needed/requested to develop and implement the skills needed at the service line level to meet expectations.

  8. Agree with comments above. Decision making at the service line level is critical and to be effective must have clear guidelines (guardrails). Clear metrics are essential. Mentorship and training to elevate skills in management and decision making are key. “Just Culture” of safety (ok to make mistakes, support from leadership) with accountability (productivity, quality, performance) can support effective service line performance and leadership.

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