Decision Making

1. Decision Making AFAMS Leadership Lesson

2. Objectives • Describe various problem-solving models: Individual versus group decision-making, and managerial decision-making styles. • Analyze issues and set appropriate priorities • Identify and analyze problems, including writing a problem statement and applying critical thinking to a situation. • Identify leadership actions to ensure the decisions are effectively implemented • Evaluate results and take corrective action if necessary • Generate and evaluate alternative solutions to a problem.

3. Module Outline • I. Decision Making and Problem Solving • II. Problem Identification and Analysis • III. Implementation of the Decision

4. I. Decision Making and Problem Solving

5. The Pervasiveness of Decision Making • Almost everything a leader does involves decision making: • What should be our goals and objectives for next year? • How should resources be allocated? • Who should be promoted? • What gets included in the agenda for the next committee or staff meeting? • What should be done regarding a patient safety concern or medical error? • Thus, medical leaders must have the skills and tools to assist them in making these and many other decisions.

6. Types of Decisions • Programmable decisions: • Repetitive decisions that often use predetermined guidelines. • Usually made by front-line managers and staff. • Examples are: determining eligibility for care, scheduling appointments, and ordering of supplies • Nonprogrammable decisions: • Decisions for which there are no easy, ready-made solutions. • Examples are deciding on whether to start or expand a service or what actions to take in response to recent patient complaints.

7. Problem-Solving Model • Problem solving is a process by which leaders analyze situations and make decisions that cause organizational results to be more like those desired.

8. Problem-Solving Model Identifying and Analyzing the Problem Generating Alternatives Making a Decision Implementing the Decision Evaluating the Decision

9. Problem-Solving Model Identifying and Analyzing the Problem • This step includes recognizing that a problem or opportunity exits, formulating a problem statement, and analyzing the causes of the problem. • Critical thinking is required for identifying current problems.

10. Problem-Solving Model Identifying and Analyzing the Problem Generating Alternatives Making a Decision Implementing the Decision Evaluating the Decision

11. Problem-Solving Model • This step involves the identification of all possible solutions to the problem. • Frequently used tools are group brainstorming, and discussion among those involved in the situation. Generating Alternatives

12. Problem-Solving Model Identifying and Analyzing the Problem Generating Alternatives Making a Decision Implementing the Decision Evaluating the Decision

13. Problem-Solving Model • In this step a decision is made on what course of action to take. • Frequently used tools for decision making are the decision matrix, motivating, and guided or facilitated discussions. Making a Decision

14. Problem-Solving Model Identifying and Analyzing the Problem Generating Alternatives Making a Decision Implementing the Decision Evaluating the Decision

15. Problem-Solving Model • This step requires the leader to develop the implementation plan, communicate the decision, and obtain commitment (“buy-in”) of the decision. • Frequently used tools in implementation are the pilot study, an action plan, and the responsibility matrix. Implementing the Decision

16. Problem-Solving Model Identifying and Analyzing the Problem Generating Alternatives Making a Decision Implementing the Decision Evaluating the Decision

17. Problem-Solving Model • This step consists of a continual review of the effectiveness of the decision. • Frequently used tools in this step are: the OODA (Observe, Orient, Decide, and Action) Loop, in-progress reviews, and the control chart. Evaluating the Decision

18. Individual vs. Group Decisions • The very first decision that you must make as a manager is to decide whether or not to involve others in a decision. • Four situational factors are most critical in making this determination: • Availability of information • Complexity of the problem • Time constraints • Level of commitment (“buy-in”) of staff to implement the decision

19. Individual vs. Group Decisions • Leaders can make individual decisions (without input or involvement from the group) when these conditions exist: • Time is critical • The problem is relatively simple to solve • Relevant information is readily available to the manager • The decision will likely be accepted by those who will carry out the implementation

20. Individual vs. Group Decisions • Group involvement is appropriate when: • There is sufficient time for consultation/discussion • The problem is complex • Information or perspective is needed from others • Group commitment is needed to implement the decision

21. Decision-Making Styles I • 1. The manager solves the problem or makes the decision alone • When to Use: If the leader has all the information or time is critical • Caution: Manager may not know what information is critical; also the decision may not be accepted by the group

22. Decision-Making Styles II • 2. The manager obtains information from subordinates/group and then makes the decision • When to use: If information is needed from others, the problem is relatively simple to address, and the solution is likely to be accepted by group • Caution: Could be viewed as manipulative if overused

23. Decision-Making Styles III • 3. The manager shares the problem with, and gets ideas/suggestions from, selected individuals within the department/group, and then makes the decision • When to use: If you need others to fully understand the basis of a relatively complex problem so they can offer better ideas/suggestions • Caution: Some group members could feel “left out” and strongly resist the decision

24. Decision-Making Styles IV • 4. The manager shares the problem with the entire group, obtains their ideas and suggestions, and then makes a decision. The decision may not reflect the general consensus of the group • When to use: Same as in #3, but also to obtain more commitment to the decision as the entire group was consulted; also used when the manager wants to retain the right to override any solution developed by a group • Caution: Could be viewed as manipulative, particularly if ideas or suggestions were often not adopted

25. Decision-Making Styles V • 5. The manager shares the problem with the group and together they make a decision • The manager is willing to accept and implement any decision made • When to use: If you need a high level of support and commitment from the group to implement the decision per the maxim, “people will support what they help create” • Caution: Should never be used if there is a chance you will veto or change the decision of the group

26. Problem Solving Pitfalls I • 1. Working on problems that are too general, too large, or not well-defined • 2. Jumping to a solution before really analyzing the problem • 3. Failing to involve critical decision markers or employees affected by the problem when identifying the problem and solutions • 4. Tackling problems that are beyond the control or influence of the individual or team/group

27. Problem Solving Pitfalls II • 5. Applying “pet” solutions rather than seeking a creative solution • 6. Failing to develop good reasons for choosing a solution • 7. Failing to adequately plan the implementation and evaluation of the chosen solution

28. Barriers to Decision Making I • Errors made by managers who make poor decisions: • Not allocating enough time for decision making, particularly for group deliberations and the reaching of consensus • Not using tools (brainstorming, cause-effect diagrams, etc.) to assist with the problem-solving process • Not willing to make a decision, being risk adverse, and continually desiring more information before making a decision (“the paralysis of analysis”) • Not listening to subordinates/staff (e.g., “Please don’t confuse me with facts, my mind is made up!”)

29. Barriers to Decision Making II • Not waiting to offer ideas or solutions (offering your ideas on a solution early during a discussion often inhibits subordinates from offering their ideas or suggestions) • Engaging in “defensive avoidance” by denying that a problem exists, exaggerating the advantage of the chosen alternative, or trying to get someone else to make a decision • Not being aware of the phenomenon of “group think” – Where officers are deterred from offering their own individual opinions

30. II. Problem Identification And Analysis

31. Problem Identification and Analysis • The first phase of problem solving consists of three steps • 1. Recognizing that a problem or gap exists • 2. Formulating a problem statement • 3. Analyzing the problem, including its root causes • These 3 steps will be described in the following slides

32. Conditions that Require Problem Solving • 1. Crisis / Immediate problem • The areas we most often associate with “problem solving” • 2. Deviation • Gap in performance from what is expected • 3. Improvement • Enhancement of systems and processes, often done to improve quality of patient care, or to reduce costs • 4. Opportunity / Threat • Strategic areas to address to take advantage of a market opportunity or to counter a threat from a competitor

33. The Problem Statement • A good problem statement has four components: • 1. An invitational stem (e.g., “In what ways can…”) • 2. An ownership component (e.g., “we”) • 3. An action component (e.g., “reduce patient waiting time in the ER”) • 4. A goal component (e.g., “by at least 20 per cent within 30 days”)

34. Problem Statement: Key Questions • Has evidence for the problem been gathered through a rigorous needs assessment? • Have those affected by the problem been involved in generating data about the problem and agreed on the problem statement? • Has the problem been defined too narrowly? • Has the problem statement been challenged by all stakeholders? • If the problem involves methods and/or resources, has it been linked to key result areas at the appropriate level?

35. Problem Analysis: Key Questions I • What are all of the relevant facts that describe the background of the current situation surrounding this decision? • What do we all need to understand? • What assumptions are we operating under? • Which of these assumptions are still valid? • What constraints, boundaries, or political realities should we take into account?

36. Problem Analysis: Key Questions II • When does the problem manifest itself? • What are the trends over time? • Who might be affected by the problem? • What is the urgency or priority in solving the problem? • Why is the problem occurring?

37. Tools for Problem Analysis I • Asking “why” to determine root causes is the most important question during problem analysis. • It should be asked repeatedly to ensure that the true, underlying causes are identified.

38. Tools for Problem Analysis II • Fish-bone diagram (cause-effect analysis) • Purpose: Used to gather together all possible causes of a problem with the ultimate goal to uncover the root cause(s) • Key steps: • Start with the problem statement • Determine the major categories in which problems may exist, e.g., Manpower, Materials, Machines, Methods, Management; these would be the major bones of the fish-bone diagram • Brainstorm and identify the possible sub-causes to the possible main causes (sub-branches to the fish-bone)

39. Example of Fish-Bone Diagram Communication Timing Discharged patient did not leave Admitting that staff is unaware bed is clean Called Housekeeping too Late Unit clerk unaware of discharge or transfer Patient Waits for Bed Physician did not write order Too Many Transfers Admissions Quota Inappropriate Admitting Procedures Physician Procedures Hospital Procedures

40. Tools for Problem Analysis III • Root-cause analysis (RCA) • Purpose: • Used to identify the basic or causal factor(s) that underlie problems or variations in performance • Most often used to in response to a sentinel event • Key Steps: • Identification of underlying process and systems problems • Analysis that asks “Why?”; then when answered, “Why?” again, and so on • Inquiry to all areas appropriate to an event or problem, including supervision and training of staff, equipment and technology, and communication among healthcare providers

41. Tools for Problem Analysis IV • Critical thinking • Used to systematically view a problem, including: • All of its ramifications • Pattern(s) of occurrence • Relationships to other issues • Broader context within the organization, including how the problem is affected by or affects other entities, systems, or processes

42. Tools for Problem Analysis V • Critical thinking • Key Skills Required: • Analysis to identify relationships among problems • Inference to form hypothesis on what is happening and to draw reasonable conclusions subject to further research/study • Self-regulation to test one’s own assumptions regarding the problem and how it should be resolved

43. Characteristics of Critical Thinkers I • Inquisitiveness on a wide range of issues • Remaining well informed • Alertness to opportunities • Trust in the process of reasoned inquiry • Open-mindedness regarding divergent views/opinions

44. Characteristics of Critical Thinkers II • Flexibility in considering alternatives • Honesty in facing one’s own biases, prejudices, stereotypes, or egocentric tendencies • Prudence in suspending, making, or altering judgments • Willingness to reconsider and revise one’s own views

45. Tools for Generating Alternatives I • Group Brainstorming • Used when a high degree of creativity is needed, when a group is stuck in current thinking or approaches, and/or when there is a need to get more individuals involved or energized • Key Steps • Nonjudgmental, spontaneous “whatever comes to mind” listing of ideas on a flip chart • Review the list of ideas, asking for clarity and discarding duplicate comments

46. Tools for Generating Alternatives II • Brainwriting (“6-5-3” Method) • “Levels the playing field,” particularly if some group members are introverted or otherwise hesitant to speak up due to a perceived status difference or the presence of supervisor(s) • Key Steps: • Six or more people each have five minutes to write down three or more ideas on a piece of paper • Each person passes his/her sheet to the next person who has five more minutes to add three or more ideas (hence, the “6-5-3” Method)

47. Tools for Generating Alternatives III • Nominal Group Technique (NGT) • As above, NGT “levels the playing field”; also, NGT allows everyone to see ideas as they are displayed, thus facilitating the consideration of each idea • Key Steps • Individual, silent generation of ideas • Sharing/posting of these ideas in a round-robin

48. Tools for Decision Making I • Multivoting • Used to set priorities for a large number of alternatives • Key Steps: • Individuals are given a number of votes (usually 25% of the total number of alternatives) • Each person can then place their votes on the alternatives they feel are best • The votes are totaled to identify the high priority alternatives • Guided discussions are used to come to consensus on a decision/solution

49. Tools for Decision Making II • Guided/facilitated discussions, using ground rules for decision making • Used to ensure participation and input from all members of a group or team and to obtain consensus on a decision • Key Steps: • Setting ground rules for decision making and group consensus (see next section) • Using facilitation practices of questioning, summarizing, checking, etc.

50. Tools for Decision Making III • Decision Matrix • Provides a high degree of rigor to the comparison of alternatives • Key Steps: • Identification of decision criteria • Listing of alternatives • Comparison of alternatives against all criteria