2.3.

HEALTH CARE DECISION

MAKING FOR
MAKIN MEGA PROBLEMS

2.3.1. Introduction
Decision-making may be ewed as the process of selecting a course of
action from among several alternatives in order to accomplish a desired
action
esult. The purpose of decision-making is to direct human behaviour and
commitment towards a future goal. It involves committing the organisation
and its resources to a articular choice of course of action thought to be
suficient and capable of achieving some predetemined objective.

aManagers at all levels in the organisation make decisions and solve

problems. In fact, decision-making is the process of reducing the gap
between the existing situation and the desired situation through solving
 problems and making use of opportunities. A decision| is conclu
Is concl

reacned after consideration; it occurs when one opioD Seiccied,lo

Exclusion of others - it is rendering ofjudgment.

Decision-making and problem-solving

are both crucial
managen
by all lea
managemA
abilities (knowledge, skills, attitudes and values) required
non-clinical)
\eaden
within
level managers
managers (clinical and
and practitioners
ve Decision-making
and problem-solving ying
healthcare organisatio. the cognitive processes of
symonymous-they
both relate to alternative.
amost suitable
Purposeful
selection ofthe most
action/intervention.
Related to a course of of goals, outhP
2) optimal
attainment

That is most likely to facilitate

3)
and outcomes.

a solution to a particu
focused on finding
Problem-solving is that could
-

in addition
to decision-making
opposed
problem, as
also focusproactive dimensions
on
problems
-

solutions to
finding of plans, strategies, policies a
such as the development
management, undesirable gap between
can be def+ned
as an
standards. A problem worker's ability to comple
observed state that hinders a
expected and in organisations and
are ofe
Problems occur frequently
the iask. if changed, could resulh
or procedures that,
reflected as faulty systems to problen
How employees respond
organisational improvement. the quality
encountered on the job is a
critical factor in facilitating
outcomes. Part of the solution
delivery
service and attainment of potential probler
them become
empowering employees and having
solvers could be to use a common problem-solving process throughou
the organisation. Typically, most organisations are structured in th
and problems encountered a
usually hierarchical pyramid fashion
of authority within t
pushed up' the decision-making line
organisation and not being dealt with where it occurs.
The characteristics of strategic decisions taken in a healthcar
organisation are the following:
1) Strategic decisions must be directed towards defining the healthecat
organisation's relationship to its environment.
2) The decision must take the healthcare organisation as a whole u
of analysis.
3) Decisions must be multi-functional in character in that it depends
input from a variety of primary functional areas.
4) The decision must provide direction for and constraints
administrative and operational activities throughout the healthca
organisation.
Healn

Decision Making Process

2.3.2. and implementing decisions is a central function of
Making and

management,
andit is where healtlhcare managers concentrate their
To facilitate
making ecisions, healthcare managers need to rely
ettorts.
and mathematical tools of management science. To
statistical

and other important

decisions, leadership. influence,
the
on
on
implement Success depends on whether or not
skills come into play. made and
behavioural

are both implemented. Although

enough right decisions
ouich right action that
turn out as planned, a plan of
decisions do not always
Haisions a successful
decision will include the following
improves
improves the
chances of
steps:
Identification of Problem Identification of Problem and its
Step 1: identifying Nature
Nature: Correctly
and its
is the most important part
the problem said
the process. It has often been Specification of Objective and
of is half Decision Criteria
well-defined problem
that a identified
solved. An improperly
problem will cause all remaining steps Development of Alternative
healthcare
to be misdirected. Often,
the symptoms of an
managers focus
on
of
underlying problem, allowing it to Analysis and Comparison
Solutions must Alternative
Surface again later.
not the
tackle the underlying problem,
Analysing and Comparing
symptoms.
Altermatives
Step 2: Specification of Objective
and Decision Criteria: the
Early on, Alternative
the
must identify Selection of Best
healthcare manager
criteria by which the solution will be
1omulated. Some examples of the Implementing of Choice
profit,
criteria include costs, return on
investment, increased productivity,
risk, company image, and the impact the
Controlling and Monitoring
on demand. Decision-Making

Step 3: Development of Alternative: The chances of finding an

adequate solution to a problem increase when suitable altenatives are

developed. Since there are probably limitless alternatives for any given
problem. a healthcare manager always runs the risk of ignoring superior
aliematives. It is extremely ailiCult to recognise and investigate every
possible outcome of the coimpiEX Inter-relationships that are influenced
b y a decision.
 of Alternative: Compiline
Step 4: Analysis and Comparison
alternatives often depends on the healt
ing
healththcan
suitable
realistic mix of the nature sitr
of the
manager's level
of experience as well as on
solution are enhance
ion are enhanced uation
of developing a satisfactory
The chances
holistic view of
the problem and then taking the ti
tin
developing a ective is to sele
The objective
alternmatives. selec
carefully identify
promising
total set carefully. It
should be bo the
after considering
the
do nothing at all.
borne i
best one
may be to
alternative
mind that the best
Alternatives: It can usualv
and Comparing health
Step 5: Analysing programmes
that give a skilled
cae
facilitated by computer
and statistical techniques for doing so. S. Such
although they should not
mathematical
manager the
in making decisions,
tools aid managers
the art of management.
A mathematical mod
for
treated as substitutes healthcare procee
representation of some real-world
is an abstract
system, or sub-system.
It depends on the objectivesse
Alternative:
Step 6: Selection of Best the criteria set for evaluating the altermative
decision-maker and
by the astute healthcar
mathematical model. In the end, the
offered by the ask the following question Which alternative best fi
man1ger should constraints
reasonable time and cost
m established objectives within whole? Decidingtha
healthcare organisation as a
and will benefit the as firs
and of course is just as important
can be a perplexing challenge,

carefully identifying the problem.

Choice: Then implementing
the chosen
Step 7: Implementing of it into action.
altenative is simply a matter of putting

the Decision-Making: Effective

Step 8: Controlling and Monitoringthe results
decision-making requires monitoring ofthe decision to make
have not, the healthcare manager
sure that they occur as desired. If they
entire process. On the other hand, investigation
may choose to repeat the
and/or the calculations, or
may uncover an error in the implementation
entire process. The later
perhaps a false assumption that affected the
Siuations can often be remedied quickly and at much less cost than
starting over.
Decisions are not always made in a concise and sequential way. *
healthcare manager will often have to backtrack to uncover errOrs, *
well as to solicit feedback from other managers and employe
nsure
especially in terms of developing and analysing alternatives. To ensu
that the organisation benefits from the best solution, it is essential
involve the persons who will be affected by the decisions a manag
makes.
2.3.3.
ProblemS risk DeciSIon Making
certain type of involved in all
Thereis decisions, in addition to
other ctor that have important bearing on the kind of decision
fäctor

sation structure can be designed to facilitate

o r g a n i s a t
made
The
ound decision to
ion and
minimise lorces that inhibit and generate
good decision-
e following administrative problems affect
making. The
naking decision-making
of Decisions: he probability thata particular
C o r r e c t n e s s

1)
1) decision
be correct depends on a number of factors,
will

and accuracy of
including tie
amount

decision-
information
gathered the
and abilitymade the
to analyse data correctly. Attempts are
of

achieve the highest percentage of correct decisions

possible and, if
ichakes
mist
are made, to ensure hat they are limited to minor
decisions
Eavironment of Decisions: A manager may be reluctant to make
decisions because of the organisational climate. Decisiveness on the
aart of top administrators will help to promote decisiveness
part
throughout the organisation. If a manager is unclear about the
authority to decide or the responsibility to decide, however
decision-making tends to be uncertain, erratic, or non-existent. If
decisions are rescinded over and over again, the manager will wait
until he or she can clear decisions with higher administration and
thus will become too cautious and slow to decide.

3) Psychological Elements in Decision-Making: Decision-making

involves both personal and organisational factors. Personal factors
that may influence an individual's organisational decision-making
include status, prestige,
economic security, temperament,
view
ntelligence, energy, attitude, and emotions. The psychological
in
is that an individual's total personality must be considered
analysing the decision-making process.

)Timing of Decisions: Those affected by a decision, including

manner. SupervIsors
Superiors, need to be informed in a timely
subordinates so that the
should always be informed ahead of their
QeCision can be effectively communicated downward.

communicaling
Communicating Decisions: Timing is important in
leaks through the
in
because undue delay may result
cCISion the
Leaks be distorted, arousing antagonisms toward
pevine may shouldbe
before it is formally announced. Major decisions
ISion should uderstand
is

"Wiung. Those affected by the decision versions or

both the written and oral
r relevance; therefore,
communication should be clear and simple.
) Participating in Decision-Making: When individuals are
allow
to participate in the decision-making process there is a sene
belongingnmess on the part of employees, improved work efficien
agreater sense of responsibility, and a greater acceplance of chan
To summarise, employees are more willing to carry out the demang
demand,
of the decision if they had a part in the decision-making process.

2.3.4. Techniques for Improving Healthcare

Decision-Making
Various techniques can be used to enable managers to make effective

decisions. which are as follows:

Techniques for Improving
Healthcare Decision-Making

Decision Tree Cause-and-Effect Diagrams

Linear Programming Waiting Line Model/Queuing Theory

Probability Analysis
Pay-Off Matrix

Break-Even Analysis
PERT and CPM

Decision Tree: It is graphic display of the available alternatives,

1) a
the outcomes, risks and information needs for a specific problem
alternative decision
period of time. The problem and each
are
over a

graphically displayed in conjunction with the probable

consequences of each alternative. As
the sequence of the major
decision is drawn, the resulting diagram resembles a tree with
branches. The process starts with a primary decision that has at least
two altermative solutions. The outcome of each
solution should be
considered. The manager can base her/his decision on
a

consideration of various alternatives and their probable

decisions may be
consequences and should realise that subsequent
dependent on future events (see figure 2.2):
Once-off Consequences
Altermativel Future Event

Chance Future Consequences

Altemative2 Event
Decision

Chance Future Consequences

Alternative 3
Event

Figure 2.2: Decision Tree

 decision tree is used irom right to left, and calculations are made
to show the benefits or potential problem areas. An event node is
represented with a square; a decision node is represented with a
circle. Visually a typical decision tree looks like a sideways tree,
branches are represented by the choices that one has to makc,
accompanied with the probability factor.
To improve decision-making and increase efficiency, doctors
must

learn when to make judgements based on intuition

versus a

systematic, analytic approach. Both types of reasoning have pros

and cons, making it all the more difficult for physicians to know
when to employ each.

Cause-and-Effect Diagrams: This device is also referred to

as the

resembles a fish
fishbone diagram, because the completed diagram
of the fish, and major causes
skeleton, with the problem as the head
as fish fins
and tail. The aim of this diagram is to analyse
The one-level cause-
relationships among multiple problem factors.
to include minor factors that
and-effect diagram can be expanded
predispose to the major problem
causes.

used for optimally

3) Linear Programming: It is a quantitative tool
among competitors
scarce resources
uses to maximise
allocating
The resources may be human,
benefits or minimise losses.
informational. Linear programming is, e.g.,
financial, physical or least costly
which route is the shortest or
capable of determining
to follow.
quantitative
Queuing Theory: It is
a
Line Model
4) Waiting of waiting lines. The objective of
tool for analysing the costs
between the
is to achieve an optimal balance
queuing theory of time individuals,
cost of increasing
service and the amount
service. The problem is to
or materials must wait for
apparatus
between the cost of upgrading
determine the best balance
amount of time users
of a service must
service potential and the
can be
situations, the queuing theory
wait in line. In such service
solution for maximising
applied to identify an optimal
while minimising costs.
refers to the
The term 'probability'
) Probability Analysis: that an outcome
expressed as a percentage,
estimated likelihood, calculated figure
this analysis, a mathematically
Will occur. In of each
the value, in monetary terms,
can indicate to management
considers objective
and subjective
alternative. The manager
her/his optimistic and pessimistic
own
options according to
 wlhich alternative will render th
the a
philosophy and guesses
desirable results.
establishing pnsible pay,
technique for
is
6) Pay-0MMatrix: It a
diflerent c o u r s e s of
action. F'ach .
retuns, from pursuing
of nature, or circumstances ntances
or
different states ym
pursued under d e c i s i o n - m a k e r .
the control of the
o financial technique which is desite.
7) Break-Even Analysis: It is
al which a specific project covers cgt
wws
to calculate the point
It requires a forecast of the sales vol
begins to show a profit. ume
and the cost of production.
Evaluation and Revision Techni.
8) PERT and CPM: Programme q
(PERT) and the Critical Path Method (CPM) are method,
network analysis. They are useful in the planning of large an
complex projects and helpto ensure that all steps are completed
the correct order and time.

2.3.5. Models for Decision-Making for Mega.

Problems
A vast number of decision-making and problem-solving models and
theories are available. The following psychological types of problen

solving are, however, briefly discussed: from a factual

) Sensing and Feeling: Decisions are approached
point of departure. Decision-makers feel oriented, tactful and
highly receptive to the approval of others. A trusting relationship
exists with others and managers have favourable expectations of
one another, thus promoting a team spirit environment. The focus
is on human relationships whereby inadequate performances are
tolerated longer than warranted and disciplinary measures are
avoided.

2) Sensing and Thinking: Managers tend to focus on the issue

rather than people and do not delegate effectively. Managers are
conscientious in carrying out their duties and responsibilities
through short-term planning and the related managerial
functions.
3) Intuitive Thinking: Managers act objectively and impersonally
while focusing on the changes and new opportunities. An
entrepreneurial focus is displayed, and complex and unstructured
problems are addressed. Enthusiastic managers act as vision
leaders who become over-involved in the strategic concems of the
 organisation and could lose sight of 81
the organisation. Excellence is nal functioning of
praise is often forgotten. expac
loyees; however,
4) Intuitive Feeling: The manag r
cibjlities from a personal point
pos
of view. With
on changes and
ommunicatation skills, they their good
articipative
participati conceptualise
management. They tend to
and apply the
principles of
implementing control to oversee that over-delegate
without
accomplished, and limit their delegated tasks have been
disciplinary role.
2.3.6. Guidelines for Healthcare
doling decisions about healthcare can seem Decision-Making
The intensity of decision-making is overwhelming at times.
magnified when life-threatening
llness is involved. The stakes feei very
arises.
high
for every choice that

Almost all decisions related to healthcare in

approached by using the following framework:palliative situations can be
1) Be Informed: Information is the foundation on which one builds
its
approach to healthcare decisions. The person and the healthcare
team must be asinformed as possible about what is
being
considered, and about the potential outcomes of different choices.
One will also want to find out as much as one can
about what is
happening with the illness.

2) Determine the Goals: From a strong foundation of information one

can begin to
explore the choices about tests, treatments, and other
healthcare considerations. This exploration should be guided by the
goals that one is hoping to achieve. n a way, goals are like a lens
that focuses our thinking.

) Avoid Assumptions: Unless goals are openly and specificaly

discussed, one can make incorrect assumptions about the hopes and
expectations of others.

For example, a patient may be assuming that chemotherapy is

being given with the goal of curing a cancer, while the doctor
The
ay be hoping to decrease its size or slow its progression.
to
Octor may have used the word "treatable", intending convey the
nat the cancer will be reduced with treatment, however,mean
word to
Operul patient and family interpreted this
"curable.