KỸ NĂNG RA QUYẾT ĐỊNH

VÀ GIẢI QUYẾT VẤN ĐỀ

GS, TS, BS LÊ HOÀNG NINH

 MỤC TIÊU
– Giải quyết vấn đề là gì
– Các dạng ra quyết định
– Các yếu tố ảnh hưởng đến ra quyết định
– Quá trình ra quyết định
– Kỷ thuật ra quyết định
– Phương pháp giải quyết vấn đề
– Các bước trong giải quyết vấn đề
– Các yếu tố quyết định trong ra quyết định và giải
quyết vấn để
 Đại cương
• Để đối phó với hệ thống y tế hiện nay đòi hỏi
người thầy thuốc phải được chuẩn bị để có
những suy nghĩ thấu đáo để có thể ra các
quyết định hay giải quyết các vấn đề găp phải
trong quá trình công tác
• Bất kỳ người quản lý, lãnh đạo nào cũng phải
đầu tư suy nghĩ và hành động để giải quyết ,
ra các quyết định để lãnh đạo cơ quan , đơn vị
đạt được mục tiêu cơ quan đơn vị
 Ra quyết định là gì

• Ra quyết định là tiến trình nhận thức Có Hệ

Thống để chọn ra được cái phù hợp nhất, tốt
nhất trong các giải pháp khác được đề nghị
 Tình huống ra quyết định
• Tình huống ra quyết định là bối cảnh mà quyết
định được đưa ra . Nó có thể mang tính chất cho
cá nhân, hay tình huống lâm sàng, hay một cơ
quan , một tổ chức :
– Ra quyết định cá nhân : một phần thường gặp trong
cuộc sống
– Ra quyết định lâm sàng: liên quan đến chất lượng
chăm sóc hay vấn đề năng lực chuyên môn
– Ra quyết định cơ quan : chọn giải pháp để giải quyết
vấn đề của cơ quan đơn vị và đạt đến mục tiêu cơ
quan, đơn vị
Sự khác biệt giữa ra quyết định
và nói/ thông báo các quyết định
 Nói các quyết định
(decision talking )

• NÓI CÁC QUYẾT ĐỊNH :

– Sự phán quyết được chọn lựa từ hai hay nhiều giải

pháp khác nhau. Nó là bước cuối cùng của ra
quyết định
 Giải quyết vấn đề
( problem solving)

• Giải quyết vấn đề :

– Là một phần của ra quyết định. Là một tiến trình
mang tính hệ thống tập trung trên phân tích tình
huống khó khăn, phức tạp. Giải quyết vấn đề luôn
luôn bao gồm các bước ra quyết định
– Là một tiến trình mà việc chọn lựa ( thế tiến thoái
lưỡng nang ) cần được xác định và chỉnh sủa ( is a
process whereby a dilemma is identified and
corrected )
 Giải quyết vấn đề

• Vấn đề là gì ?
– Là tình trạng hiện không thỏa nhu cầu cần phải
thay đổi để đáp ứng với đòi hỏi như mong đợi

– Sự khác biệt so với các chuẩn kỳ vọng làm cản

trở việt đạt tới mục tiêu của cơ quan
 Giải quyết vấn đề
• Giải quyết vấn đề và ra quyết định ?:

• Many educators use the terms problem solving

and decision making synonymously, but there is
a small important difference between the two.
Although decision making is the last step in the
problem solving process, it is possible for
decision making to occur without the full
analysis required in problem solving. Because
problem solving attempts to identify the root
problem in situations, much time and energy are
spent on identifying the real problem.
 Sự liên quan giải quyết vấn đề
và ra quyết định
 Decision making and problem solving used
inconsistently or interchangeably.
 The two process appear similar and may in some
instances depend on one another, they are not
synonymous.
 The main distinctions between the two are that
decision making may or may not involve a
problem, but it involves selection of
alternatives.
 Whereas problem solving involves diagnosis a
problem and solving it, which may or may not
entail deciding on one correct solution.
 Most of the time, decision making is a subset
of problem solving
 Ba dạng chính trong ra quyết định
• A. Quyết định thường qui : ( routine decision):
– Khi vấn để dễ xác định, phổ biến và đã có luật, chính sách
và qui trình thực hiện giúp giải quyết như: thiếu bs trong
bệnh viện
• B. Quyết định thích nghi ( adaptive decision):
– là các quyết định khi vấn đề và giải pháp khác thường. Thí
dụ thay đổi giờ và kiểu hình làm việc, cách điểm danh nhân
viên....
• C. Quyết định cải cách ( innovative decision) :
• Là các quyết định khi vấn đề là bất thường và chưa rõ
khi đó cần các giải pháp sáng tạo để giải quyết : thí du
: tỷ lệ nhiễm trùng vết mổ lên đến 50 %
 Levels of decisions
Levels of decisions

Strategic Operational
Administrative
 Các cấp độ quyết định
1. Quyết định chiến lược ( strategic decision ):
– Quyết định được ra bởi những lãnh đạo về những kế
hoạch hoạt động dài hạn...
– Được gọi là chiến lược do nó tập trung trên các mục
tiêu dài hạn của cơ quan đơn vị
2. Quyết định hành chánh ( administrative
decision) : thường được ra bởi cán bộ quan lý
cấp trung gian ( khoa/ phòng...) : giải quyết
những vấn đề bất thường và phát triển các kỹ
thuật đễ cải thiện chất lượng công việc
 Các cấp độ quyết định

• 3. Quyết định vận hành ( operational decision)

: là các quyết định thường qui liện quan đến
các sự kiện/ biến cố hàng ngày , thường do
cán bộ cấp cơ sở ( first line) hay trung gian ra
quyết định
 Những yếu tố ảnh hưởng đến việc ra
quyết định
1. Experience and knowledge
2. Creating thinking
3. Self concept
4. Stress
5. Interpersonal conflict
6. Time available, money, energy
7. Routine # non routine decision
8. Risk associated decision
9. Critical nature of work
10. Written guidelines
11. Organization attitude toward decision making
12. Amount and kind information available
13. Degree of acceptance and support
14. Manager personal ability
 Decision making process

Characteristics of effective decision making process:

• Conducted in a systematic, comprehensive way of

thinking.
• The consequences of the implemented decision are
determined.
• Results in positive outcomes and fewer negative
consequences.
• Based on a "Goal-oriented" analysis of the situation,
its problems, and their alternative solutions.
Decision making process
 Qui trình ra quyết định
(Decision making process)
1) Defining the problem:
Bạn phải nói rõ vấn đề , chính xác vấn đề
là gì ? Thí dụ Increase Medication
errors), you may lack information to
define it
you can confuse symptoms with
underlying causes
Prepare a statement of the problem and
find someone you trust to review it
and to talk it over.
2- thu thập thông tin từ đâu ?
Stakeholders:
”Individuals, groups, organizations that are affected by the
problem or its solution”.
Facts & data
- Results from experimentation and studies.
- Interviews of "experts" and trusted sources.
- Observed events, past or present, either personally
observed .
Boundaries
The boundaries or constraints of the situation are difficult to
change.
Opinions and Assumptions
Opinions of decision makers, committees or groups, or other
powerful groups will be important to the success of your
decision. It is important to recognize truth, bias, or prejudice
in the opinion.
3) Phát triển các giải pháp (Develop
Alternatives)

Look at the problems in different

ways; find a new perspective that
hasn’t thought of before. Once you
have listed or mapped alternatives, be
open to their possibilities. Make
notes on those that:
Need more information.
Are new solutions.
Can be combined or eliminated.
Will meet opposition.
Seem promising or exciting.
4) Cân nhắc các giải pháp (Weigh Alternatives )
After listing possible alternatives,
evaluate them without prejudice,

Consider all criteria while a suitable

solution may solve the problem, it may
not work if resources aren't available, if
people won't accept it, or if it causes
new problems
5. Select the best alternative
Don't consider any alternative as "perfect solution." If
there were, there probably wouldn't be a problem in
the first place
Consider your intuition, or inner feelings in deciding on
a course of action
Return to a trusted outsider: Is there something you
missed?
Does he/she see a problem with your solution?
Compromise when you have a full grasp of the
problem, and your alternatives
Techniques in weighing alternatives:
1-Thomas Saaty's Analytical Hierarchy Matrix:
List alternatives in columns and rows as depicted in the matrix
above. Starting with Alternative A, go across columns in the
matrix and rate each alternative against all the others.

When the alternative under consideration has more value than the
others.

Then give the more valuable alternative a score of 1

When the alternative has less value than the others.

Then give the less valuable alternative a score of 0

2- SFF Matrix: thích hợp, khả thi & mềm dẽo:

Suitability Feasibility Flexibility Total

Alternative A

Alternative B

Alternative C

Alternative D
A-Suitability: refers to
the alternative itself, whether it is ethical or practical. Is it
appropriate in scale or importance? An adequate response? Too
extreme?

B-Feasibility: refers to
how many resources will be needed to solve the problem (i.e. Is it
affordable?)

How likely will it solve the problem?

C-Flexibility: refers to
your ability to respond to unintended consequences, or
openness to new possibilities? The alternative itself and
whether you can control outcomes once you begin.

Total a score for each alternative, compare, prioritize your

alternatives...
Develop a plan for implementation. Its elements
include:
 Step-by-step process or actions for solving
the problem.
 Communications strategy for notifying
stakeholders.
 Where important or necessary, inform
those who care for you and/or will be
affected by the change. Prepare them as
necessary about your decision.
 Resource identification/allocation.
 Timeline for implementation
7) Monitor progress

if results are not what you expect, review your options

and alternatives

Whether or not you achieved your goals, it is important

to consider what you have learned from your
experience: about yourself, about what you consider
important.

Lastly, if you have done your best, you have this as one
measure of success.
 How to improve decision making
1- interpret data in more than one way.
2- set criteria of success beforehand .
3- ask other people
4- lest your failure
5- improve feedback by avoid missing and confuse
6- scrutinize the decision making process
7- Change your way of deciding and reevaluate your time,
and learning from experience
8- have group do decisions audits too.
9- be rational.
 How to improve decision making?
10 Educate people so they know how to make appropriate decision.
11.Seeking support of top management for decision making at the
lowest possible level, (e.g decentralization)
12.Successful manager stay informed about decision being made at
different levels of the organization after appropriately
delegating these responsibilities.
13.The managers should deal only with these decisions requiring their
level of expertise (non routine decisions), support implementation
of decisions, and credit the decision maker.
14.Delegation of decision making (routine decision making) to
subordinates to gain their trust, loyalty and to raise their self-
esteem.
15.Successful manager who is skilled in both decision making and
problem solving serves as a motivator and role model for
others
 PROBLEM - SOLVING

PROBLEM SOLVING PROCESS

 Traditional Problem-Solving Process

The traditional problem-solving model is widely used and is

perhaps the most well known of the various models. The seven
steps follow. (Decision-making occurs at step 5.)

1. Identify the problem.

2. Gather data to analyze the causes and consequences of the
problem.
3. Explore alternative solutions.
4. Evaluate the alternatives.
5. Select the appropriate solution.
6. Implement the solution.
7. Evaluate the results.
 Traditional Problem-Solving Process

Although the traditional problem-solving process is an effective

model, its weakness lies in :

1. the amount of time needed for proper implementation. This

process, therefore, is less effective when time constraints are a
consideration.

2. lack of an initial objective-setting step. Setting a decision goal

helps to prevent the decision maker from becoming sidetracked.
The Managerial Decision-Making Process

The managerial decision-making model, a modified traditional

model, eliminates the weakness of the traditional model by
adding a goal-setting step. Harrison (1981) has delineated the
following steps in the managerial decision-making process:

1. Set objectives.
2. Search for alternatives.
3. Evaluate alternatives.
4. Choose.
5. Implement.
6. Follow up and control.
 Decision making techniques

Decision making techniques vary according to the nature

of the problem or topic, decision maker, situation, and
decision making method or process.

Nurses are using tools such as cause- and- effect

diagrams, flow charts, Pareto charts, run charts,
histograms, control charts, and scatter diagrams to help
understand facts and relationships in processes they are
examining.
 Decision making techniques

1. Group decision making:

A number of studies have shown that professional people

do not function well under micromanagement.

Group problem solving casts the manager in the role of

facilitators and consultant.

Compare to individual decision making , group can provide

more input and better decision.
 Decision making techniques

2. Nominal group technique (NGT)

-It is eliciting written questions, ideas, and reactions from

group members.
Consists of :
-Silently generating ideas in written.
-Round-robin presentation by group members of their ideas
on a flip chart.
-Discussing each recorded idea and evaluate.
-Voting individually on priority ideas, with group solution
being derived mathematically through rank ordering.
 Decision making techniques

3. Delphi technique

It is judgments on a particular topic are systematically gathered

from participants who do not meet face to face.

Useful when expert opinions are needed .

 Decision making techniques

4. Statistical aggregation:

Individuals are polled regarding a specific problem and their

responses are tallied .
like Delphi technique , does not require a group meeting.
no opportunity for group members to strength their
interpersonal tie or interaction.
 Decision making techniques

5. Brainstorming
The idea generating technique wherein a Group members meet and
generate diverse ideas about the nature, cause , definition, or
solution to a problem without regard to questions of feasibility or
practicality. Through this technique, individuals are encouraged to
identify a wide range of ideas. Usually, one individual is assigned to
record the ideas on a chalkboard. Brainstorming may be used at any
stage of the decision- making process, but it is most effective at
the beginning, once a problem has been stated.
 Decision making techniques

6. fishbone diagram (causes and effect)

Is drawn after a brainstorming session, the central
problem is visualized as the head of the fish, with the
skeleton divided into branches showing contributing
causes of different parts of the problem.
 Fishbone diagram (Cause and effect)

Resources
and facilities

shortage of physical plant

space

lack of availability of ground ambulance transportation

limited resources of ED in the form of medical
Lack of supplies and medications
Unavailability of operating room time

Ancillary services not same hours as ED ED Overcrowding

No system available for supervising &evaluating work

Lack of availability of 24-hour laboratory tests
Increased medical records documentation requirements
Increase length of stay due to waiting for test
Delay in the services provided by radiology, lab.
and ancillary services
Delay in treatment and prolonged patient stay in
ED
Work system
7. Thomas Saaty's Analytical Hierarchy
Matrix

Decision making techniques vary according to the nature of the

problem or topic, decision maker, situation, and decision making
method or process.
 Thomas Saaty's Analytical Hierarchy
Matrix
List alternatives in columns and rows as depicted in the
matrix above. Starting with Alternative A, go across
columns in the matrix and rate each alternative against all
the others.
When the alternative under consideration has more value
than the others,
Then give the more valuable alternative a score of When
the alternative has less value than the others.
Then give the less valuable alternative a score of Add the
scores for each row/alternative; highest score is the
highest rated alternative according to the criteria you
used. In the matrix above, Alternative C scores highest,
so it's the highest rated alternative.
 Problem solving

Problem solving methods:

Trial-and-error method :one solution after another is

tried until the problem is solved or appears to be
improving.

Experimentation: a theory is tested to enhance

knowledge, understanding , or prediction.

Affinity map : a tool used to identify problems.

 Steps in problem solving

1- define the problem

2- gather information
3- analyze the information
4- develop solutions
5- Make a decision
6- implement the decision
7- evaluate the solution
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

1. Define Objectives Clearly :

• If a decision lacks a clear objective or if an objective is
not consistent with the individual’s or organization’s stated
philosophy, a poor-quality decision is likely. Sometimes the
problem has been identified
but the wrong objectives are set. Problems can be
extremely complex and may need multiple objectives
(Clancy, 2003).
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

2. Gather Data Carefully:

Because decisions are based on knowledge and information
available to the problem solver at the time the decision
must be made, one must learn how to process and obtain
accurate information. The acquisition of information
begins with identifying
the problem or the occasion for the decision and continues
throughout the problem-solving process.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

2. Gather Data Carefully:

Because decisions are based on knowledge and information
available to the problem solver at the time the decision
must be made, one must learn how to process and obtain
accurate information. The acquisition of information
begins with identifying
the problem or the occasion for the decision and continues
throughout the problem-solving process.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

Questions that should be examined in data gathering are:

1. What is the setting?
2. What is the problem?
3. Where is it a problem?
4. When is it a problem?
5. Who is affected by the problem?
6. Is this your problem or someone else’s problem?
7. What is happening?
8. Why is it happening? What are the causes of the problem? Can
the causes be prioritized?
9. What are the basic underlying issues? What are the areas of
conflict?
10. What are the consequences of the problem? Which is the most
serious?
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

3. Generate Many Alternatives :

- When seeking alternatives, individuals need to expand their
horizons; the most common trap managers fall into is limiting the
borders of their decision frames.

- Because everyone thinks uniquely, increasing the number of

people working on a problem increases the number of alternatives
that can be generated.

- Brainstorming is another frequently used technique. The goal in

brainstorming is to think of all possible alternatives
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

4. Think Logically :
People think illogically primarily in three ways.
1. Overgeneralizing. This type of “crooked” thinking occurs when one
believes that because A has a particular characteristic, every other A
also has the same characteristic. An example of this thinking is when
stereotypical statements are used to justify arguments and decisions.
2. Affirming the consequences. In this type of illogical thinking, one
decides that if B is good but he or she is doing A, then A must not be
good. For example, if a new method is heralded as the best way to
perform a nursing procedure and the nurses on your unit are not using
that technique, it is illogical to assume that the technique currently
used in your unit is wrong or bad.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

3. Arguing from analogy. This thinking applies a component that is

present in two separate concepts and then states that because A is
present in B, then A and B are alike in all respects. An example of this
would be to argue that because intuition plays a part in clinical and
managerial nursing, then any characteristic present in a good clinical
nurse also should be present in a good nurse–manager. However, this is
not necessarily true; a good nurse– manager does not necessarily
possess all the same skills as a good nurse– clinician.
CRITICAL ELEMENTS IN PROBLEM SOLVING AND
DECISION MAKING

5. Choose and Act Decisively :

Individuals may become vulnerable at this last point in the
problem-solving process and choose to delay acting because
they lack the courage to face the consequences of their
choices. For example, if managers granted all employees’
requests for days off, they would have to accept the
consequences of their decision by dealing with short
staffing.
INDIVIDUAL VARIATIONS IN DECISION MAKING

Because everyone has different values and life experiences,

and each person perceives and thinks differently, different
decisions may be made given the same set of circumstances. No
discussion of decision making would, therefore, be complete
without a careful examination of the role of the individual in
decision making
INDIVIDUAL VARIATIONS IN DECISION MAKING

• Values
• Life experience
• Individual preference
• Individual ways of thinking and decision making
INDIVIDUAL VARIATIONS IN DECISION MAKING

1. values:

Individual decisions are based on each person’s value system.No

matter how objective the criteria, value judgments will always play a
part in a person’s decision making, either consciously or
subconsciously. The alternatives generated and the final choice
selected are limited by each person’s value system.

Because values also influence perceptions, they invariably influence

information gathering, information processing, and final outcome
INDIVIDUAL VARIATIONS IN DECISION MAKING

2. Life Experience:
Each person brings to the decision-making task past experiences that
include education and decision-making experience. The more mature
the person and the broader his or her background, the more
alternatives he or she can identify.
3. Individual Preference:
With all the alternatives a person considers in decision making, one
alternative may be preferred over another. The decision maker, for
example, may see certain choices as involving greater personal risk
than others and therefore may choose the safer alternative. Physical,
economic, and emotional risks, and time and energy expenditures, are
types of personal risk and costs involved in decision making.
INDIVIDUAL VARIATIONS IN DECISION MAKING

4. Individual Ways of Thinking and Decision Making :

Our way of evaluating information and alternatives on which we base our
final decision constitutes a thinking skill. Individuals think differently.
Some think systematically—and are often called analytical thinkers—
whereas others think intuitively. It is believed that most people have
either right- or left-brain hemisphere dominance.

Some feel that there is a gender difference in how we think and behave.
Rudan’s research (2003) looked at how male and female leaders behaved
differently and noted that males and females socialized and
communicated differently; males paid much less attention to
relationships and resisted being influenced. These differences have the
potential to effect decision making.
OVERCOMING INDIVIDUAL VULNERABILITY I
DECISION MAKING
1. Values :
Overcoming a lack of self-awareness through values
clarification decreases confusion. People who understand their
personal
beliefs and feelings will have a conscious awareness of the values on
which their decisions are based.
2. Life experience:
a person can do some things to decrease this area of vulnerability:
-use available resources, including current research and literature, to
gain a fuller understanding of the issues involved.
-involve other people, such as experienced colleagues, trusted
friends, or superiors, to act as sounding boards and advisors.
- analyze decisions later to assess their success.
OVERCOMING INDIVIDUAL VULNERABILITY IN
DECISION MAKING

3. Individual Preference :
Overcoming this area of vulnerability involves self-awareness, honesty,
and risk taking.
4. Individual Ways of Thinking :
People who make decisions alone are frequently handicapped because
they are not able to understand problems fully or make decisions from
both an analytical and intuitive perspective. However, in most
organizations, both types of thinkers may be found. Using group
process, talking management problems over with others, and developing
whole-brain thinking also are methods for ensuring that both intuitive
and analytical approaches will be used in solving problems and making
decisions. Use of heterogeneous rather than homogeneous groups will
usually result in better-quality decision making
DECISION MAKING IN ORGANIZATIONS

Since organizations are made up of people with differing values and

preferences, there is often conflict in organizational decision
dynamics.

1. Effect of Organizational Power on Decision Making

Powerful people in organizations are more apt to have decisions
made (by themselves or their subordinates) that are congruent with
their own preferences and values. On the other hand, people
wielding little power in organizations must always consider the
preference of the powerful when they make management decisions.
Power is frequently part of the decision factor (Good, 2003). In
organizations choice is constructed and constrained by many
factors, and therefore choice is not equally available to all people.
DECISION MAKING IN ORGANIZATIONS

2. Rational and Administrative Decision Making

most managerial decisions were based on a careful, scientific, and
objective thought process and managers made decisions in a
rational manner. In the late 1940s, Herbert A. Simon’s classic
work revealed that most managers made many decisions that did
not fit the objective rationality theory. Simon (1965) delineated
two types of management decision makers: the economic man and
the administrative man.
 Comparing the Economic Man with the
Administrative Man
Economic
Makes decisions in a very rational
manner
Has complete knowledge of the
problem or decision situation.
Has a complete list of possible
alternatives.
Has a rational system of ordering
preference of alternatives.
Selects the decision that will
maximize utility function.
Administrative
Makes decisions that are good
enough.
Because complete knowledge is not
possible, knowledge is always
fragmented.
Because consequences of
alternatives occur in the future,
they are impossible to predict
accurately.
Usually chooses from among a few
alternatives, not all possible ones.
The final choice is “satisficing”
rather than maximizing.
 Summary

The decision making process may employ several models:

rational or normative, descriptive or bounded rationality,
satisfying, and political.

Decision making techniques vary according to the problem and

the degree of risk and uncertainty in the situation.