Operating in recurrent crises: a qualitative study of decision-making and unintended consequences in a peripheral hospital.

Background: During crises, decision-makers often operate under uncertainty, relying on limited evidence and intuition, increasing the risk of unintended consequences. In Israel, hospitals have recently faced back-to-back crises: the COVID pandemic and the war following October 7th 2023. Objective: This study aimed to explore hospitals' decision-making processes during crises and how managing one crisis influenced responses to subsequent crises. Methods: We conducted a qualitative study guided by a modified version of the World Health Organization's six building blocks framework, and interviewed 18 key decision-makers in a peripheral hospital. Deductive framework-informed thematic analysis compared decision-making during routine operations versus crises. Results: We found that decision-making processes narrowed primarily to managing COVID-19, with heightened oversight of COVID wards and increased interactions with external factors such as the Ministry of Health. Although mechanisms to minimize unintended consequences existed during routine times, non-COVID areas were often deprioritized during the crisis, increasing the risk of unintended consequences. Notably, the pandemic served as a catalyst for organizational learning, strengthening staff preparedness and improving operational and logistical capabilities during the subsequent war. Furthermore, interactions established during the pandemic contributed to streamlined wartime decision-making. Conclusion: Decision makers should capitalize internal and external collaborations developed during crises to sustain them during routine times for better preparedness. Moreover, they should mitigate the risk of unintended consequences in non-crisis-related services, which are particularly vulnerable during emergencies. It could be achieved by regular and systematic real-time evaluation checkpoints in place. Future multi-center studies are needed to assess the transferability of these findings across diverse settings and crisis contexts.