Volume 9 no 1

PERSPECTIVE: Lessons in crisis decision-making learned from Canada’s COVID-19 health care response

Wael M.R. Haddara, MD


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PERSPECTIVE: Lessons in crisis decision-making learned from Canada’s COVID-19 health care response

Wael M.R. Haddara, MD


The rapidly changing nature of the COVID-19 pandemic presented many health care institutions with unique challenges. Although the Canadian response was generally strong, several gaps in leadership and decision-making became apparent. This paper presents reflections on key health care decision-making principles through the retrospective prism of the pandemic.


Keywords: decision-making, COVID-19, leadership


Haddara WMR. Lessons in crisis decision-making learned from Canada’s COVID-19 health care response. Can J Physician Leadersh 2023;9(1):5–8



The COVID-19 pandemic presented institutions at all levels with unprecedented challenges. Although the Canadian health care system had been preparing for a pandemic for many years — and had indeed experienced a prior coronavirus-related public health crisis — several factors conspired to make this an unprecedented situation that required new ways of managing. This was, perhaps, not wholly unexpected; as von Molthke astutely observed, no plan survives first contact with the enemy.1


The discipline of disaster and crisis decision-making has produced standard operating procedures for managing incidents.2 A further body of literature exists regarding decision-making under the mnemonic VUCA (volatility, uncertainty, complexity, and ambiguity).3 Such literature is informed by studies in cognitive and behavioural psychology that tell us that the human mind is complex and that decisions are not always entirely rational.4


This paper is a series of reflections about the intersection of front-line leadership and institutional and organizational response. I write from the perspective of a critical care physician at an academic hospital. As chief of critical care, I was heavily engaged in our institutional response to COVID-19. I was also involved in regional and provincial planning as we developed a model for predicting hospitalizations and ICU admissions. Although I occasionally refer to the underlying theory, my primary intent is to share personal experience, rather than to provide a systematic overview of the literature. The hope is that readers will find some utility in these observations when considering their own experiences.


Leadership lessons


1. Evaluate options simultaneously rather than sequentially

In rapidly evolving crises, decisions are often viewed as sequential and binary: mandating vaccines or not; donning N95 masks for all encounters or only for aerosol-generating procedures, etc. Making decisions sequentially based on a limited assessment of options can lead to suboptimal choices that are not completely consistent with individual and organizational values.5 In more elaborate decision-making processes, multi-attribute utility theory (MAUT)6 and the Pareto frontier7 are used to evaluate many options simultaneously and to generate a set of options. The selected options are then compared. Under rapidly changing conditions, such as an evolving pandemic, such elaborate processes may not be possible or desirable, but the concept should inform the construction and selection of choices.


2. Invest in data infrastructure

Evidence-based decision-making is rooted in relevant, accurate, and widely available data. This is recognized in such standards as the ISO-9001 evidence-based decision-making standard.2 In novel crises, the data needed to make decisions may not be readily available on a “push,” real-time basis. There is a temptation to resort to a manual “pull” approach to extricate relevant data, especially if such information is needed daily. However, building the infrastructure required to automate data collection and verification is essential.


Representing the data in a way that facilitates relevant sense-making and action is another important element. For example, representing the inventory of personal protective equipment (PPE) as “days on hand” using pre-pandemic usage levels is not helpful to guide decision-making at a time when PPE use is an order of magnitude higher than usual.


3. Separate data from analysis

The analysis of data and/or information is at the heart of effective and evidence-based decision-making. Repeatedly presenting raw data to decision-makers rather than its analysis is time-consuming and distracting. Indeed, decision-makers have a vested interest in critical analysis, as “Critical thinking is the bridge between information and decision-making.”5 Try to provide decision-makers with analysis and recommendations.


4. Critically examine underlying assumptions

Analysis is often predicated on certain assumptions. In the context of COVID-19, a common assumption was the applicability of other jurisdictions’ experience to our own without regard to similarities or differences in health care systems, the impact of climate, the relevance of population density and age demographics, etc. Public health guidance on the efficacy of masking is an example where critical examination of underlying assumptions was important and ultimately led to changes in messaging: the limited utility of masks at the individual level translated into significant reductions in transmission because of the large population at risk. Understanding assumptions is essential to understanding the limitations and predictions of analyses. Ensuring that assumptions are explicitly shared may help frame the limitations of an analysis for decision-makers and enable better decision-making, especially when evaluating trade-offs.


5. Clarify roles and responsibilities of relevant stakeholders

In the emotionally laden world of crisis, confusion around “decision-making rights” can result in loss of trust and a sense of outright betrayal. In health care organizations, loss of trust can spiral into diminished engagement of physicians and staff. Adopting a decision-making model, such as RAPID (recommend, agree, perform, input, decide)8 or RACI (responsible, accountable, consulted, informed),8 to clarify roles and responsibilities early in the crisis management process is crucial in avoiding such outcomes. As the crisis evolves, the makeup of each group may be in flux. Revisiting the RAPID or RACI chart on a recurrent basis is one way to ensure that relevant stakeholders remain engaged. Open and regular communication through staff forums, daily updates, or other accessible means alerts others to the notion of a changing environment and the need to engage a previously uninvolved group.


6. Embrace feeling uncomfortable

H.L. Mencken noted that for every complex problem there is an answer that is clear, simple, and wrong.9 Incident management teams are designed to move quickly. When consensus is achieved rapidly, this can confer a misguided sense of comfort with the quality of the decision. Janis theorized that “groupthink” is a stress-reduction mechanism and that crises are stressful situations that may make such approaches even more attractive.10


Under conditions of uncertainty and ambiguity, an easily achievable consensus should be a red flag. In any sufficiently diverse organizational structure, some individuals will express alternative ideas, but may feel an inclination to withdraw their dissent to facilitate faster decision-making. This is especially so if they perceive themselves to be the persistent voice of doom. Yet, there is a case to be made that unwarranted optimism is a greater threat to effective decision-making than pessimism.11 The elimination of a “contrarian” perspective may well lead to a lower-quality decision process. Leaders should seek out and listen carefully to opinions and views that go against the majority perspective.


7. Do not unduly delay decision-making

Most people are risk-averse, and action is associated with higher perceived risk than inaction. “We hope vaguely, we dread precisely.”12 Risk aversion may be exacerbated by stress13 and amplified when making decisions for others rather than ourselves.14 Inaction can be rationalized as a sense that something better may come along. And it is possible that a delay will allow better information to become available; however, in most cases, decision-makers delay a difficult decision simply because the options are unappealing. In those situations, delays can lead to outcomes that are worse for the waiting. When the temptation arises to delay a decision, questions must be asked. Are new/better options likely to present themselves if we delay a difficult decision? What specific information are we waiting for? What is the cost of delaying the decision?


8. Manage the impact of changing information and decisions

In our ICU, we recognized early on that new information about COVID-19 would lead to changing decisions. We found, for example, that emerging safety data on PPE for medical procedures made previous decisions seem suboptimal or even unsafe. We instituted two basic principles and socialized those through frequent staff meetings. The first is that we developed and effectively disseminated information about key processes based on the available best practices, and we reviewed those regularly. The second — and I argue the more important — is that we socialized the idea that using the best available data at the time usually leads to the right decision. If new data lead to a different course of action, that does not mean the original decision was wrong; it was still the best decision under the circumstances. However, just as it was important to revisit decisions, algorithms, and pathway when new data became available, the opposite was also important, which leads to the next point.


9. In the absence of new information, do not revisit decisions

If the decision-making process is robust and nothing has changed in terms of new information or data, leaders should have the discipline to refrain from revisiting decisions. Although this may seem like a basic management statement, it is difficult to adhere to under rapidly changing conditions. The potential for analysis-paralysis under volatile or uncertain conditions is limitless. The desire to revisit decisions can lead to the diversion of valuable cognitive and other resources from more important tasks. If an organization finds itself repeatedly reconsidering its responses, that should be a warning that the decision-making process is not robust: the appropriate stakeholders are not engaged, enough options are not generated, the pros and cons are not properly evaluated, and so on.


10. Separate the “possible” from the “necessary”

Crises are often associated with resource limitations. As such, choices may have to be based on what is available rather than on best practice. For example, N95 masks were deemed necessary in certain situations, but because of supply shortages, practice moved away from the intended single use of N95 masks to make-shift protocols for prolonged or repeated use with rationing and sterilization. The necessary condition of masking was met by doing what was possible at the time. This is not to say that leaders must reassure people that “everything is fine.” In a crisis, everything is not fine. A more truthful and transparent position is to explain that “this is not the safest/best course of action, but it is the safest/best course of action possible. And we will do better as soon as it is possible.”15 Reassurance is better provided through honesty than over-optimism.




COVID-19 was, and remains, an unprecedented challenge to leadership both at the front lines and at the institutional and organizational levels of health care delivery. It is essential that we learn from our experiences while they are still fresh in our collective memories. I hope that the leadership principles I found useful will be helpful for others in managing crises, whether present or future.



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Wael M.R. Haddara, BScPharm, MD, FRCPC, MMEd, is chief of critical care at London Health Sciences Centre, University Hospital, in London, Ontario.


Correspondence to: