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AFAMS Leadership Lesson
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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.
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Module Outline
I. Decision Making and Problem Solving
II. Problem Identification and Analysis
III. Implementation of the Decision
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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.
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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.
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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.
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Problem-Solving Model
Identifying and Analyzing the Problem
Generating Alternatives
Making a Decision
Implementing the Decision
Evaluating the Decision
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Problem-Solving Model
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.
Identifying and Analyzing the
Problem
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Problem-Solving Model
Identifying and Analyzing the Problem
Generating Alternatives
Making a Decision
Implementing the Decision
Evaluating the Decision
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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
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Problem-Solving Model
Identifying and Analyzing the Problem
Generating Alternatives
Making a Decision
Implementing the Decision
Evaluating the Decision
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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
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Problem-Solving Model
Identifying and Analyzing the Problem
Generating Alternatives
Making a Decision
Implementing the Decision
Evaluating the Decision
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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
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Problem-Solving Model
Identifying and Analyzing the Problem
Generating Alternatives
Making a Decision
Implementing the Decision
Evaluating the Decision
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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
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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
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Individual vs. Group Decisions
Leaders can make individual decisions (without input or involvement from the group) when these conditions exist:Time is criticalThe problem is relatively simple to solveRelevant information is readily available to the
managerThe decision will likely be accepted by those
who will carry out the implementation
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Individual vs. Group DecisionsGroup involvement is appropriate when:
There is sufficient time for consultation/discussion
The problem is complexInformation or perspective is needed from
othersGroup commitment is needed to implement the
decision
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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
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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
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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 decisionWhen 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
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Decision-Making Styles IV4. 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 groupWhen 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
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Decision-Making Styles V5. The manager shares the problem with the
group and together they make a decisionThe manager is willing to accept and
implement any decision madeWhen 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
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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
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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
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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!”)
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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
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Problem Identification and Analysis
The first phase of problem solving consists of three steps1. Recognizing that a problem or gap exists2. Formulating a problem statement3. Analyzing the problem, including its root
causes
These 3 steps will be described in the following slides
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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
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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”)
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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?
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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?
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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?
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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.
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Tools for Problem Analysis IIFish-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)
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Example of Fish-Bone Diagram
Communication
Admitting that staff is unaware bed is
clean
Unit clerk unaware of discharge or transfer
Patient Waits for
Bed
Physician Procedures
Physician did not write order
Admissions Quota
Timing
Hospital Procedures
Too Many Transfers
Inappropriate Admitting Procedures
Discharged patient did not
leave
Called Housekeeping too
Late
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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
problemsAnalysis that asks “Why?”; then when answered,
“Why?” again, and so onInquiry to all areas appropriate to an event or
problem, including supervision and training of staff, equipment and technology, and communication among healthcare providers
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Tools for Problem Analysis IV
Critical thinkingUsed to systematically view a problem,
including:All of its ramificationsPattern(s) of occurrenceRelationships to other issuesBroader context within the organization,
including how the problem is affected by or affects other entities, systems, or processes
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Tools for Problem Analysis VCritical 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
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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
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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
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Tools for Generating Alternatives I
Group BrainstormingUsed 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
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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)
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Tools for Generating Alternatives IIINominal 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 StepsIndividual, silent generation of ideasSharing/posting of these ideas in a round-
robin
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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 bestThe votes are totaled to identify the high priority
alternativesGuided discussions are used to come to
consensus on a decision/solution
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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.
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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 alternativesComparison of alternatives against all criteria
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Decision Criteria IDecision Criteria
The keys to effective decision making are the clear delineation of all decision criteria and the evaluation of all alternatives against these criteria.
Some common decision criteria are:1. Effectiveness in solving the problem2. Feasibility of implementation3. Cost of implementation4. Financial benefits, e.g., cost-effectiveness5. Non-quantitative advantages, e.g., public
image6. Political acceptance7. Timeliness (implementation in a reasonable
time frame)
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Decision Making Ground Rules
Decision-making ground rules or guidelines should be established for groups to ensure that all issues are fully discussed and consensus is reached.
Managers should be aware of the phenomenon known as “group think”.
Group think occurs whenever the desire for harmony and a quick decision overrides the needs for critical evaluation of a problem.
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How to Avoid Group Think I
1. Assign the role of critical evaluation to each group member
2. Have the leader avoid seeming partial to one course of action
3. Create subgroups and have each work on the same problem
4. Have group members discuss issues with outsiders and report back
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How to Avoid Group Think II5. Invite outside experts to observe and react to
group processes
6. Assign someone to be a “devil’s advocate” at each meeting
7. Write alternative scenarios for the intentions of competing groups
8. Hold “second chance” meetings after consensus is apparently achieved
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Ground Rules for Decision Making Free, open discussion with issues and ideas candidly
put “on the table” for debate and consideration
Non-attribution of comments
Review/clarification of what was said and subsequent distribution of an executive summary after each meeting
Consensus is being able to live with the outcome of any decision after having full opportunity to provide input
Use of an iterative process whereby members obtain input from their own service/stakeholders. This input is then fed back to the working group for further consideration.
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Guidelines for Group Consensus I
Do not argue blindly, consider others’ reactions to your points
Do not change your mind simply to reach agreement (avoid group think)
Do not avoid conflict by voting, coin tossing, and bargaining
Try to get every group member involved in the decision-making process
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Guidelines for Group Consensus II
Allow disagreements to surface so information and opinions can be deliberated
Do not focus on winning versus losing, seek alternatives that are acceptable to all (“win-win” situations)
Discuss assumptions and listen carefully to the perspectives of others
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Leader Responsibilities
Leadership is the most important factor in the successful implementation of any decision.
The leader must:Plan for the implementationCommunicate the decisionObtain commitment (“buy-in”)Follow up to ensure that the decision was
implemented as planned.
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Tools for Implementation Planning I
Action Plan Purpose: Delineates exactly what needs to be
done to implement a decision The action plan identifies:
What needs to be accomplishedWho is responsible for that task When the task must be completed How well (metric to measure success)
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Tools for Implementation Planning II
Responsibility Matrix Displays the action plan in a matrixThe responsibility matrix goes one step further
by identifying those who support the primary owner of the task and those with whom the task needs to be coordinated
Development of a matrix that lists all members of the group/team and all tasks that need to be accomplished
Assignment of responsibilities to each task along with target dates for completion of the task
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Tools for Implementation Planning III
Pilot Tests a solution prior to full implementation
Implements a solution in one specific area
Uses results to make changes as necessary prior to full scale implementation
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Obtaining Ongoing Support from Organization I
MediaThe manager should use multiple media
sources (e.g., newsletters, bulletin boards, etc.) to announce and generally explain certain decisions.
This should create awareness that a change will soon be seen in the HCMO, department, or unit.
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Obtaining Ongoing Support from Organization IIStaff Meetings
The leader would discuss: Overview of the decision (change being implemented)
Why the decision was made, and how it will address future needs of the organization
How the solution benefits both the organization and the staff (e.g., “what’s in it for them”)
How the decision will be implemented, including the timetable and what will be done if problems are encountered
Everyone’s role in making the implementation a success
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Obtaining Ongoing Support from Organization III
Support from Opinion LeadersOpinion leaders are those whom the staff respects
or frequently interacts with due to their expertise, knowledge, or personality.
Before a decision is actually implemented, the leader should:Seek out opinion leaders in the organization. Ask for their supportAddress any concerns that they haveSolicit their input on how to effectively
implement the decision, particularly in overcoming any possible resistance
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Obtaining Ongoing Support from Organization IV
Managing by Walking AroundGet a first-hand view of how the decision is
being implemented
Asking for input from the staff on how the implementation is progressing and what can improve the process
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Reinforcement and Rewards
Reinforcement and RewardsFollow up on each item of the action plan,
providing gentle reminders of responsibilities and due dates
Put in place new policies and procedures that “cement” the implementation of the decision
Show appreciation and recognize those who have successfully implemented the decision
Publicize success via newsletters, e-mail, etc.
Share lessons learned, particularly with other units who will later implement the decision
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Evaluating the Decision:Feedback Loop
1. Observe Fact-finding (examining the current situation and the
changed reality)
2. Orient Assessment of one’s position vis-à-vis the changed
situation
3. Decide Rapid decision for a new course of action due to new
circumstances
4. ActionImplementation of a new course of action without
delay
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Evaluating the Decision:In Progress Review I
Reviews should be held once every month to review how the decision is being implemented and the results thereof, particularly to identify if changes are needed.
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Evaluating the Decision:In Progress Review II
Review of ResultsThis consists of evaluating changes or trends as
compared with previous months, internal benchmarks or targets, and external benchmarks, if available.
Reports from Responsible Individuals This consists of a review of reports and/or
discussions with those responsible for each major implementation task.
It is particularly important to determine the current status of the implementation and to identify any barriers currently being encountered.
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AFAMS Leadership Lesson