Hospital-affiliated higher education institutions face a multitude of challenges and uncertainties, from a decline in enrollment to financial instabilities to large-scale health-system mergers. These higher education organizations must adapt in order to overcome challenges and remain sustainable in the future. Previous research was limited regarding decision-making for higher education institutions during organizational adaptation. The purpose of this qualitative study was to explore higher education leaders' perceptions of decision-making practices during organizational adaptation in small, hospital-affiliated healthcare colleges during the post-COVID-19 timeframe. Semi-structured, in-depth interviews were conducted with 11 presidents and provosts of colleges who are members of the Consortium of Hospital-Affiliated Colleges and Universities. The findings revealed several themes and subthemes, including mission guidance, multifaceted decision-making factors, situational decision-making, the need to overcommunicate, and leader characteristics during the decision-making process. The proposed recommendations set forth in this study could be used by hospital-affiliated higher education leaders to aid or enhance their current decision-making practices when small or large-scale adaptations need to occur. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com.bibliotheek.ehb.be/en-US/products/dissertations/individuals.shtml.]