Simple vs complicated vs complex decisions: a leader’s approach (HBR and Colin Powell) and a reflection

How does electronic Surgical Case Request and electronic Informed Consent illustrate decision-making in complex environments? Here is some of my own heartburn. Also, what does Colin Powell have to say about decision-making?

In our monthly meeting, our surgeon informaticist and I were discussing our Electronic Surgical Case Request and Electronic Informed Consent projects, and the swirling, interconnected decisions we are facing, and it occurred to me that we were facing a COMPLEX project with challenging decisions to be made.

In brief, I recall from an HBR article (A Leader’s Framework for Decision-making) that there are simple, complicated, complex and chaotic environments.

from Cinefin framework
  • Surgical Case Requests (SCR) are currently scribbled on paper, sticky note, email, many forms – we want to make them electronic, trackable, standardized, accurate, with few to no verbal handoffs
  • We know (from others) that Case Requests and Informed Consent (IC) forms should be implemented together, synergistically
  • There are several ways to implement SCR and IC, it is unclear which pieces of hardware, and what software packages are best to use in the peri-operative space.
  • There is an idea that combining a surgical Consent and an anesthesia Consent (as is done by our Children’s Hospital colleagues) would simplify workflow and eliminate 50% of patient-required signatures, while retaining (or improving) patient-physician discussion of consent.
  • A combined consent form is a novel idea in many circles and would require consensus from: Legal, Compliance, CMO, Surgery leaders, Anesthesia leaders, IT leaders to agree on the strategy and tactics
  • It is not at all clear that surgery leaders and our 1000+ of surgeons are ready to abandon their (potentially error-prone, but familiar) existing paper/sticky-note/email/text/other-method-here workflow for this new process
  • This project MUST be completed in the next 12 months, as per C-suite prioritization
  • At a high level, we DO have buy-in from Surgery, Anesthesia, Chief Medical Officer, Chief Operations Officer, all the right stakeholders.


Do we really want to take on “Combine Anesthesia and Surgeon Consents” at the same time as these 2 massive projects? Do we?

In this case, I think we’re encountering something Complex.

How to execute this project successfully?

This is something we are wrestling with right now. One significant decision to make now:

  • Whether to use the Burning Platform of the Surgical Case Request / eConsent project to push forward the ‘combine anesthesia and surgery consents’ at the same time, OR to skip it (as it distracts from the major goal of succeeding at Case Requests and Consents across the system

Argument FOR unification of consent

  • Reduced time pressure in the peri-op area, where patients have already fasted for hours, mentally prepped for their surgery, and NOW have to meet the anesthesiologist, have a detailed discussion of risks/benefits of anesthesia, and sign a consent form
  • Reduced number of signatures a patient needs to sign
  • Reduced hardware elements that could go wrong: a electronic signature pad connected to a PC or Workstation on Wheels, an iPad running consent form software on the right patient, a patient portal account running on a smartphone or other patient’s device, receiving a consent form.
  • Reduced management of customized consent forms, as instead the anesthesiologist can focus on having a thoughtful conversation and documenting the result in the note INSTEAD of explaining a form and chasing a signature.

Argument AGAINST

  • Too much change: eliminating a consent process that has been used for decades (on paper) might result in unintended consequences, reduced quality of documentation, missed steps in the peri-operative suite
  • Risk of delay or cancellation: if we bet everything on unified consent and we have a hard-stop disagreement from Compliance office, Legal office, CMO office, Anesthesia Leadership, Surgeon Leadership, Operations Office, Nursing, Patient Advocates, will our timeline be able to survive?
  • The IT team may not be able to delete and rebuild 2 consent forms at the last minute if our governance decisions cannot keep up with project mile-stones.


In Complex Environments, leaders must watch for emergence, as there may be no prior guidance “best practice” for THIS situation. One must “probe, sense, and respond.” From early conversations, there are many objections to the proposed consent unification, and we sense that the risk to the project may be too great to insist on adding this additional objective.

In this case, I think we must simplify. There are too many risks to the timeline and major hills we already must climb for the Case Request and Consent projects to be successful. Our metrics will include:

  • Improved Accuracy of CPT coding (reduced insurance coverage rejection for incorrect CPT code) and thus $$ we have to “write off” due to clerical or administrative error.
  • Reduced patient frustration for above billing errors
  • Improved OR scheduling (right CPT code leads to better estimates of how long the procedure will take, and the right amount of time can be set aside)
  • Improved matching of surgical equipment to the right procedure and reduced need to “emergently flash-clean equipment” that is not ready

Make Decisions with 70% of Data needed?

  • Colin Powell tells us to make decisions when you have 70% of data you need, avoid making a decision when you only have 40% of the information you need. I find this: uncomfortable, and probably about right.

How to explain complexity simply?

  • One Pager: This is another example of the usefulness of building a vision of WHY, high level explanation of HOW, predict the potholes in this big project, and explain what is needed by leaders and front line to make this happen, and what will be gained as a result.

CMIO’s take?

Simplicity is the ultimate sophistication.
–Leonardo DaVinci, Steve Jobs, maybe others

Don’t under-appreciate Complexity and how to make decisions differently in such circumstances.

Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

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