*Purpose: Transplant providers are tasked with making ethically complex and high-stakes decisions of determining a patient’s candidacy for liver transplantation within a multi-disciplinary team. We aimed to conduct an in-depth observation of transplant committee meetings to focus on facilitators and barriers to efficient decision-making. Efficiency is important in transplant team decision making to make accurate decisions in a timely manner, so patients can properly and expeditiously continue to move forward through evaluation to a listing decision.

*Methods: We observed a total of 28 committee meetings at two transplant centers, taking field notes on the content of discussion, team dynamics, and decision-making process. Study team members then debriefed after committee meetings, sharing noteworthy observations. The research team analyzed the ethnographic observation field notes using inductive thematic analysis.

*Results: The study team identified several facilitators and barriers to efficient decision making in liver transplant committee meetings.

Facilitators included the uniform presentation format for each candidate. Each presentation began with a medical presentation by a physician. Discussion consistently included medical issues (led by hepatology or surgery) and psychosocial concerns (led by the social worker). In addition, visual summaries of the case were shared with the entire team during each presentation and facilitated discussion. Another facilitator of efficient decision making was that team members displayed active listening when their colleagues spoke in committee meeting, and information presented was rarely repeated.

Barriers to efficient decision-making included lack of written protocols to aid decision-making during committee meetings, especially in the case of patients with alcoholic liver disease. During difficult cases, committee team members did not indicate a shared understanding of protocols for listing, and expressed confusion or disagreement during meetings, or engaged in circular discussions. Another barrier to efficient decision making was incomplete data collection. Several times, all but one test or team member evaluation was completed prior to the patient being discussed, leading to re-presentation. Moreover, if some members of the team did not think a patient should be listed, the team displayed reluctance to exclude patients, and would often delay making this decision and defer discussion to a future meeting.

*Conclusions: More prompt data collection, and clear protocols, particularly regarding patients with alcohol-related liver disease, are needed to improve efficient transplant team decision making.

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