Decision rights redesign in a hospital network

A regional hospital network — four hospitals, one merged administration — had governance by accretion: 31 standing committees, most created to solve a problem nobody could still name. Clinical quality was strong. Administrative decisions were not: a capital request took a median 61 days to decide, and operational questions routinely visited three committees before finding one that felt authorised.

The culture was collegiate and consensus-minded, which everyone valued and nobody wanted destroyed. The brief was precise: keep the consensus where it earns its cost, and take it out of the decisions where it is only delay.

Six weeks of tracing actual decisions — 74 of them, through minutes and approval trails — showed that the network did not have a consultation problem; it had an ownership problem. For 60% of recurring decision classes, no single accountable owner existed. Committees consulted each other because none believed it could decide.

The latency was priced at roughly $3.9M a year in delayed works, locum cover extensions and equipment idle time — a number the board had never seen because it lived in no budget line.

The decision inventory became a ledger: every recurring decision class with one accountable owner, a deliberately short consulted list, and the forum where it happens. Clinical-safety decisions kept their consensus machinery intact — that was consensus earning its cost. Administrative and capital decisions moved to named owners on a fixed cadence.

Before adoption, the draft ledger was tested against the last ten significant decisions the network had actually made. The test reshaped a third of the draft — and it is why the ledger was adopted as a description of how the network works, not an aspiration it would ignore.

Latency read from calendars and approval trails, not interviews; month-11 readings verified under MKM-F-003.