The Health Care Manager
Volume 35, Number 1, pp. 80–89
Copyright # 2016 Wolters Kluwer Health, Inc.
All rights reserved.
Deciding to Decide
How Decisions Are Made and How Some
Forces Affect the Process
Charles R. McConnell, MBA, CM
There is a decision-making pattern that applies in all situations, large or small, although in small
decisions, the steps are not especially evident. The steps are gathering information, analyzing
information and creating alternatives, selecting and implementing an alternative, and following up
on implementation. The amount of effort applied in any decision situation should be consistent
with the potential consequences of the decision. Essentially, all decisions are subject to certain
limitations or constraints, forces, or circumstances that limit one’s range of choices. Follow-up on
implementation is the phase of decision making most often neglected, yet it is frequently the phase
that determines success or failure. Risk and uncertainty are always present in a decision situation, and
the application of human judgment is always necessary. In addition, there are often emotional forces
at work that can at times unwittingly steer one away from that which is best or most workable under
the circumstances and toward a suboptimal result based largely on the desires of the deci
sion maker.
Key words: constraints, decisions, decision making, emotionalism, risk
LARGE OR SMALL, 1 PATTERN FITS ALL
Most people make a great many decisions
in the course of a typical day. Many decisions,
surely the greatest number of those made in a
day, are small and made very nearly uncon-
sciously. Some decisions are indeed so elemen-
tary in scope and execution that one who might
experience difficulty making them quickly
could be considered troubled in some possibly
serious manner. Occasionally, however, some
of the decisions encountered in a workday are
significant and require considerably more con-
scious effort than the small automatically made
decisions. Some of these more significant de-
cisions can take days and weeks and even
months to finalize. The little decisions are
made as the situations arise with hardly a seri-
ous thought, whereas the significant decisions
receive what often amounts to our complete
attention. Yet little or big, each and every
Author Affiliation: McConnell Editorial Services,
Ontario, New York.
The author has no conflict of interest.
Correspondence: Charles R. McConnell, MBA, CM, 5943
WalworthRoad, Ontario, NY14519 (mclighthouse@juno.com).
DOI: 10.1097/HCM.0000000000000096
decision encompasses all of the elements of
the basic decision-making process.
Those always-present elements of the decision-
making process are the following:
1. Gathering information
2. Analyzing information and arranging it
into alternatives
3. Selecting a preferred alternative (ie,
deciding)
4. Implementing the chosen alternative
5. Following up on implementation
Rather, it should be said that the foregoing
5 elements should always be present. Four of
them are in fact always present, but 1, specif-
ically the final element, following up on im-
plementation, is sometimes overlooked. Small
decision or large decision, however, the first 4
elements are always present. Their presence,
however, may not be especially notable in the
instance of a small decision.
There are essentially 2 factors or forces that
determine the prominence of the steps of the
process of making any particular decision.
One is the amount of experience the decision
maker has had, and thus in part the amount of
‘‘preprogramming’’ that person has experienced,
and the other is the potential consequences of
the decision.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
80
mailto:NY14519(mclighthouse@juno.com
Decision Making and Forces That Affect the Process 81
Consider some simple examples, decisions
a hypothetical individual called Robert could
face today. The first example is the process
Robert goes through in determining what
necktie to wear today. He is familiar with the
clothes he owns and knows how his neckties
match up with his shirts and suits. He is work-
ing with a limited, known, field of information,
making the same general decision he has made
many times previously. His ‘‘information’’ is
what he knows of his ties and other clothes,
and his alternatives are the matches he can
possibly consider, all or most of which he has
considered previously. Choosing means pick-
ing 1 of the combinations, implementing is tying
the necktie in place, and perhaps even follow-up
on implementation is present as he glances in
the mirror to check the knot. This is a decision
made readily because Robert is so well experi-
enced at it that he is preprogrammed.
The second major force in determining the
prominence of the steps in the process is the
potential consequences of an incorrect deci-
sion. In the foregoing necktie example, the
potential consequences are negligible. If Robert
has made a poor choice, someone he encoun-
ters that day might think, probably off-handedly
or fleetingly, that he had poor taste in ties or
that he did not match up his outfit very well.
Hardly consequences of lasting or major impact
(unless, of course, Robert happens to be inter-
viewing today for an executive position with a
men’s clothing manufacturer, a circumstance
suggesting that potential consequences often
hinge, in part, on the total decision context and
not just on economics).
Take the necktie decision up a level, how-
ever, and consider that Robert has gone into a
store to purchase a new tie. This is an entirely
new situation. Unless Robert buys neckties far
more often than most men do, he will not
have nearly as much experience with this kind
of decision. Therefore, he has far less informa-
tion about his field of choices. There are dozens
or perhaps hundreds of neckties available, and
his ability to select 1 or more consistent with his
wardrobe is somewhat hampered by the fact the
except for what he is wearing, his wardrobe is at
home. Less experience translates to little or no
preprogramming, requiring Robert to ponder
more. Then there is the matter of potential con-
sequences. If he simply chose the wrong tie to
wear today, he might look a bit foolish or out of
place or he may suffer no consequences at all.
But if he makes an improper decision by pur-
chasing a necktie that turns out to be inappro-
priate for him, then he is out perhaps $20 or $30
or more.
Consider, then, decisions for Robert of
progressive importance—buying a new suit,
selecting a new automobile, or even buying a
home. At each succeeding level, chances are
he has had less and less experience with the
kind of decision he is facing, and at each
succeeding level, the potential consequences
loom larger and larger. Thus, the forces of
experience (rather, lack thereof) and potential
consequences affect the amount of effort that
goes into a particular decision. More experi-
ence, quicker decision—which is why the lit-
tle matters that are decided every day seem to
be decided automatically. And the greater the
potential consequences are, the greater the
thought and deliberation going into the deci-
sion. Or this generally should be the case, for
with what confidence would the staff go
forth if their chief executive officer made a snap
decision to launch a new, expensive program
without thoroughly examining the idea?
Essentially by definition, the first 4 elements
of the decision-making process are always
present. The first 2, gathering information
and forming alternatives, may be invisible
because of preprogramming, and the third
and fourth may seem to happen instanta-
neously. And the final step, follow-up on im-
plementation, may not always occur (more on
this later).
GATHERING INFORMATION
In addressing business decisions that may
be faced during the workday, the initial step
is always the gathering of information on which
to base each decision. If a particular decision
requires the solution of a problem, also required
is the appropriate identification of the problem.
The principal task in this phase is to assemble
information that will ultimately suggest the di-
rection of the decision to be made. The principal
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82 THE HEALTH CARE MANAGER/JANUARY–MARCH 2016
means of gathering information include re-
search, study, and—especially—observation.
Observations lead to conclusions. However,
1 of the greatest trouble spots in decision mak-
ing exists because of the human tendency to
move from observation to conclusion on lim-
ited information. Never will our information
be perfect. Some decision-making theorists
speak of the concept of perfect information,
the state of knowing everything there is to
know about a specific problem or decision
situation. Perfect information is a theoretical
ideal; it does not exist in the day-to-day world.
If it did exist, there would be no decision to
make because the appropriate alternative
would be self-evident; the decision would
have made itself.
In a practical sense, we can never know
everything about a given situation, but we
should strive to learn enough to guide and
temper our judgment in deciding. In the pro-
cess, we need to remain aware of the weak-
nesses inherent in observation and our human
tendency to infer the presence of things not
present and to discount the importance of
things not seen.
There can be considerable difference be-
tween true observation, that is, effective infor-
mation gathering, and simply ‘‘seeing what is
happening.’’ When we see something, the
image strikes the mind and we immediately
begin to catalog impressions or formulate judg-
ments about what we have seen. However, all
too frequently, we permit ourselves to misinter-
pret what has been placed before us simply
because we have seen rather than observed.
When something is seen, the visual sense is
used essentially automatically and the resulting
mental process is allowed to ‘‘just happen.’’ On
the other hand, when something is truly ob-
served, it is seen but seen with a purpose.
And because seeing is occurring with a pur-
pose, the observer is at least partially protected
against the tendency to automatically accept
surface appearances as pertinent.
Observation is a mental skill that can be
refined and improved through practice. It re-
quires strict attention to what is being observed
and genuine interest in gaining something from
the observation. It is necessary to be selective in
observation, recognizing that no one can effec-
tively observe everything. The intent should be
to observe what is worthwhile, what is perti-
nent to the problem at hand or the decision that
will have to be made.
It is also essential to remain aware that when-
ever information is taken in and reordered and
conveyed to others who will in turn make use
of it, something is lost at every step. Consider
the simple concept of cumulative informa-
1
tion losses :
1. One misses part of what is occurring
upon initial observation;
2. One omits part of what was taken in
when relating the information to another;
3. The person receiving the information
misses part of what is provided by the
original observer; and
4. The receiver of the information in turn
omits part of what was taken in when
passing the information to yet another
or expressing it in another form.
Observation, therefore, including essentially
any and all means of gathering information on
which to base decisions, is always flawed, and
thus, the information acquired is less than com-
plete except in the most elementary of situations.
ANALYZING INFORMATION AND
CREATING ALTERNATIVES
In actual practice, this supposed phase of the
decision-making process will greatly overlap
the preceding phase in which information is
collected. As information accrues, it can logi-
cally be arranged in an appropriate order and
placed in the proper context for evaluation. In
this manner, it is possible to ‘‘fill in the gaps’’
as the decision maker progresses, and this in
fact is what usually occurs. Arranging and cor-
relating data and other information as they
accrue help the decision maker address the
often-present problem of when to stop collecting
information and proceed with
deciding.
One of the common failings exhibited by
some persons in decision-making situations,
especially decision makers lacking confidence
or practical experience, is the tendency to
continue collecting information well beyond
the limits of practicality. Often, the timid or
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Decision Making and Forces That Affect the Process 83
overcautious decision maker, under the guise
of being thorough and conscientious, will con-
tinue gathering information of diminishing
value. Because a decision maker’s information
is never complete or perfect, there is always
room for asking ‘‘what if?’’ Anyone who has
spent any appreciable time in organizational
life has known a supposed decision maker
who will ‘‘if a problem to death’’ rather than
deciding.
At the opposite extreme from the ‘‘iffer’’ is
the individual who decides compulsively, emo-
tionally, with little or no substantive informa-
tion, going forward on no more than personal
preferences, ‘‘hunches,’’ and ‘‘gut feel,’’ thereby
making what is very often an inappropriate
decision. This extreme is no more tolerable
in a working manager than the extreme rep-
resented by the chronic ‘‘iffer.’’
Overall, the amount of time and effort put
into analyzing information and creating alter-
natives should be consistent with the weight
or potential consequences of the decision. In
other words, it makes little sense to pour a
dollar’s worth of time and effort into prepar-
ing to make a 10-cent decision; far from being
cost effective, this kind of overly cautious
behavior is decidedly counterproductive.
The assembling of information in order—
into evident alternative choices—as it is ac-
crued, when coupled with common-sense
judgment, should be sufficient to tell most
managers when to stop gathering and decide.
SELECTING A PREFERRED
ALTERNATIVE
Upon arriving at this point in the process,
the decision maker may discover that if the
previous steps have been appropriately thor-
ough, the decision may have almost made it-
self. That is, the analysis of alternatives may
have revealed which potential choice is ‘‘best’’
based on the available information. However,
what is the apparent ‘‘best’’ will perhaps have
to tempered with the decision maker’s knowl-
edge of what is possible. It is at this stage that
constraints must enter the picture if they
have not already done so.
CONSTRAINTS: BEYOND THIS BARRIER
YOU SHALL NOT GO
The common constraints, those circumstances
placing either absolute, partial, or practical lim-
itations on the some of the decision alterna-
tives, involve, either singly or in combination,
5 factors or forces: time, money, quality, per-
sonalities, and politics. Some constraints can
be absolute in that they present a firm, immov-
able barrier that cannot be passed. Many con-
straints, however, possess some flexibility in
that there is room for trade-offs in which it is
possible to settle, for instance, for less of 1 char-
acteristic for the sake of obtaining more of an-
other. But whether they are encountered singly
or jointly, the common constraining factors will
ultimately scribe boundaries around every de-
cision situation. The only significant difference
from one situation to another will be how much
freedom exists between the decision and the
boundary.
Time
Many activities that take place in the deliv-
ery of health care must happen in a timely
fashion. Emergency room response time must
be consistent with patient needs, for example,
and the turnaround time of laboratory tests
must be appropriate to the treatment of the
patient. Bills must be paid in sufficient time to
maintain the payer’s credibility and credit
standing. There are any number of activities
that can be made to take place more econom-
ically if it does not matter how long they have
to wait before getting done. However, many
activities simply cannot be pursued in what
might seem the most ‘‘efficient’’ manner be-
cause doing so takes more time than can be
allowed. In one way or another, time will be a
constraint in a great many decision situations.
Money
Money is perhaps the single most encoun-
tered constraint in the decision-making pro-
cess, or at least the constraint of which we
are the most aware and the constraint that is
most easily understood. Money is often an
absolute constraint; you cannot buy a $3000
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84 THE HEALTH CARE MANAGER/JANUARY–MARCH 2016
machine if you have only $2500 available, as
Robert of the earlier examples cannot buy a
$30 necktie if he has only $25 with him (and
no credit cards). In business, we understand
financial constraints better than other con-
straints probably because we can relate per-
sonally to the manner in which limitations on
the amount of money available automatically
rule out unaffordable alternatives.
Within its absolute limits, however, money
can be flexible in permitting trade-offs with
other factors. Some activities, for instance,
can be performed in less time using more
costly processes or can be allowed to require
more time using less costly inputs.
Quality
An acceptable level of quality is frequently
a constraining force. The problem, however,
is frequently one of agreeing on what is
‘‘acceptable.’’ Quality is legitimately subject
to frequent 3-way trade-offs with both time
and money, although some predetermined
level of quality will frequently be the determin-
ing factor and will in effect drive the amounts
of time and money involved.
Quality is also the least understood and,
therefore, the most abused of the constraining
factors so far discussed. The ‘‘abuse’’ referred
to is the abuse created by misunderstanding,
reflected in the tendency of many in health care
to treat cost and quality together as though they
were coupled in a direct relationship. That is, to
behave as though quality goes up as expendi-
tures go up and, conversely, quality goes down
when expenditures go down. Behind this,
there has been a long-standing tendency of
many in health care (and elsewhere—the atti-
tude is hardly unique to health care) to believe
that they way something is accomplished at
present is the most efficient way to produce
the desired quality. There follows the belief
that it is not possible to spend less money on
a particular activity without reducing the qual-
ity of its output.
The age-old cost-versus-quality controversy
has gained momentum in recent decades be-
cause of concern over the rising cost of
health care. As concern over escalating costs
translated into pressure to reduce costs, walls
of resistance were encountered among med-
ical professionals and other caregivers who
firmly believe that it is not possible to reduce
cost without adversely affecting quality. As to
whether it is or is not possible to do this, the
answer is: It depends. There is of course an
optimum relationship between cost and qual-
ity for every set of circumstances. The diffi-
culty, however, lies in the near impossibility
of determining this optimum relationship in
many situations. Frequently, however, it is pos-
sible to reduce cost without adversely affecting
quality, and sometimes, it is even possible to
reduce cost while improving quality. At other
times and in other situations, reducing cost
can indeed reduce quality. What is important
to keep in mind about the relationship be-
tween cost and quality is that it is neither di-
rect nor constant.
Personalities and politics
Although often separable and capable of
existing one without the other, these 2 areas
of constraint are discussed jointly for 2 reasons.
First, they are frequently present together—
one having its effect primarily because of the
other; and second, we are inclined to believe
that these are forces or factors that should not
exert influence on business decision making.
We may indeed agree that personalities and
politics should not place constraints on rational
decision making. However, in the real world,
they do just that and refusing to consider them
legitimate is to ignore the reality of their pres-
ence. Political considerations are a fact of life
in many health care organizations. One who
has spent any time at all working in a hospital,
for example, knows the unofficial power and
authority possessed by some medical staff
members. It quickly becomes apparent that the
physician has more clout than the nonphysician
in many instances regardless of placement in
the organizational hierarchy. It becomes equally
apparent that the strong-willed physician—
adding the impact of personality to the poli-
tics of position—can determine the fate of
any potential decision regardless of its indi-
vidual merits.
Thus, personalities and politics become
potential barriers to be reckoned with. These
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Decision Making and Forces That Affect the Process 85
sometimes place insurmountable obstacles in
the path, and they always suggest that certain
groups or individuals need to become in-
volved in making many decisions not because
of what they can contribute but because of
who or what they are. It has been proven time
and again that the surest way to guarantee the
opposition of certain individuals or groups is
to exclude them from all deliberations leading
up to a decision. On the other hand, there are
times when inclusion alone paves the way
toward cooperation in the decision-making
process. Of course, inclusion of all potentially
or even remotely involved parties will not en-
sure the acceptance of a particular decision,
and it may be necessary to spend considerable
time working out a solution acceptable to all.
But exclusion of some people because they
are only potentially or remotely involved—or
worse, exclusion of parties who are consid-
ered likely to present obstacles—moves the
situation in the direction of ensuring maximum
opposition to whatever decision is made.
CONSTRAINTS AS ABSOLUTE OR
PRACTICAL
Brief mention was made above of the fre-
quently present ability to make trade-offs be-
tween and among constraints. However, there
are some situations in which certain con-
straints must be considered absolute at a
given level. For example, if the upper limit
placed on a certain capital purchase is $3000,
then only trade-offs involving purchase costs
not exceeding $3000 can be considered. Sim-
ilarly, trade-offs involving quality are possible
only subject to maintaining a level of quality as
measured by some externally imposed stan-
dard. An absolute constraint, therefore, is a
limitation that cannot be exceeded in formu-
lating a decision alternative.
A practical constraint arises from a flexible
characteristic of a decision situation that can
become a restricting factor if flexed beyond
some point. Consider, for example, choosing a
new home. In deciding where to locate your
residence relative to where you work, you
obviously have some trade-off opportunity in-
volving distance. Perhaps you can flex with
the necessity to travel 5, 10, or 20 miles or more
to work, giving on distance to secure more of
what you want in a residence. However, if you
happen to find your dream home at a price you
can afford but it is 150 miles from work, dis-
tance has presented a practical limitation. This
can place you in a position of considering new
decisions—find new employment?—commute
weekends?—or whatever, or it can rule out
the dream-home alternative. This is a practical
constraint.
Overall, constraints delineate the partly
firm and partly flexible boundaries within
which we must operate in every decision sit-
uation. Rarely can we seriously consider all
possible alternatives. Rather, we are limited
in our choices to those alternatives that fall
within the boundaries drawn by the con-
straints of each situation.
IMPLEMENTATION
Implementation is action. It is taking the
chosen alternative and putting it to work,
and it may take a number of different forms.
Implementation may be as simple as initiating
a purchase order and in a few days or weeks,
uncrating a new piece of equipment and turn-
ing it on. On the other hand, it may be as
complex as the design and planning and other
preparation required to realize a building ex-
pansion or establish a new service.
Implementation is also everything. The
wisest, most rational, most well-considered
decision amounts to nothing unless it is put
to work. Taken in its entirety, a decision
actually has 2 major components, the choice
and the action. Without action following
choice, the decision remains hypothetical
and is thus no decision at all.
FOLLOW-UP ON IMPLEMENTATION
Follow-up is invariably the weakest and most
neglected link in the decision-making process,
and as such, it is often the stage during which
good ideas can perish for lack of attention.
One executive with whom the problems of
follow-up were discussed estimated that he
spent as much as 70% of his available time
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86 THE HEALTH CARE MANAGER/JANUARY–MARCH 2016
following up on previous decisions, ensuring
that tasks he has assigned are actually accom-
plished and that activities he has initiated have
been followed through to completion.
Now and then, follow-up may not be nec-
essary, but this is usually so only with minor
decisions of the kind that are made automat-
ically. Any decision of any appreciable scope
or potential consequences requires conscien-
tious follow-up.
The importance of follow-up on decision
implementation is readily revealed through
the observation of newly installed or recently
changed working methods and procedures. If
a form is redesigned and its initial use is not
closely monitored, shortly after its introduc-
tion, employees will begin drifting back to
the use of the old form. At times, it may seem
necessary to go through a department and lit-
erally clean out every copy of an outdated form
so it cannot be used. Likewise, in implementing
an improvement requiring a change in the way
people accomplish a task they have been per-
forming for years, you may find that without
close follow-up old habits or simple resistance
to change will carry people back toward the
original method.
Also, any new method or improved proce-
dure of any scope will consist of a number of
steps or individual parts. It is highly likely, in
fact usually true, that the revised process con-
tains flaws or inadequacies. Proper follow-up
is required to reveal these weaknesses so they
may be corrected.
The greater the potential consequences of
the decision and the broader and more com-
plex its implementation, the more follow-up is
required. Usually, a great deal of initial follow-
up will be necessary to ensure that implemen-
tation is carried out in the manner intended
and that people become accustomed to differ-
ent ways of working. Only after a certain de-
gree of familiarity develops can follow-up be
eased, and then it cannot be ended entirely
until the decision makers are assured that the
new way has become the accepted way.
It bears repeating that follow-up is often the
weakest and most neglected link in the decision-
making process, yet it is often the most critical.
As time passes after the rendering of a decision,
the circumstances surrounding that decision are
subject to change. Sometimes, a considerable
amount of unforeseen change can occur in a
short time, necessitating adjustments in the
implementation process. Overall, a manger’s
approach to following up on the implementa-
tion of a decision of any particular consequence
will include the following considerations:
1. Communication and clarification—applying
extra effort to ensure that the employees
who will be carrying out the actual imple-
mentation truly understand what is ex-
pected of them
2. Timing of implementation—especially
important in introducing changes in me-
thods and procedures, making certain that
new demands do not coincide any more
than necessary with peak workloads, other
extraordinary demands, and stressful oc-
currences (layoffs, reorganization, etc)
3. Ongoing analysis—monitoring possibly
changing circumstances that call for ad-
justments to the implementation plan;
in others words, accounting for changes
that occur between finalization of deci-
sion and completion of implementation
4. Evaluation of suggestions—remaining open
to the suggestions and input of the people
involved in the actual implementation, rec-
ognizing that no one knows the inner work-
ing details of a particular task better than the
person who does it every day
5. Withdrawing a poor choice—recogniz-
ing that not every decision will prove to
be appropriate, and if a particular deci-
sion is generating negative results despite
a conscientious implementation effort,
pulling it back and going ‘‘back to the
drawing board’’
6. Admitting mistakes—as much as it is
doing, implementation is also learning,
and when one learns he or she has made
an error, taking advantage of the imple-
mentation period to admit the error and
seek correction
7. Sticking with the right decision—having
weathered many of the storms of implemen-
tation and being convinced thereby that
the decision, although perhaps unpopular
with many, is the correct one, exhibiting the
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Decision Making and Forces That Affect the Process 87
courage and determination necessary to see
it through to complete implementation.
RISK, UNCERTAINTY, AND JUDGMENT
Earlier mention was made of the concept
of perfect information, that state that theo-
retically exists only when you know all there
is to know about every available choice. If
there truly were such a thing as perfect infor-
mation, there would be no decision to make; it
would have made itself because the only true
alternative would be self-evident.
Because perfect information does not exist,
there will always be elements of risk and un-
certainty in a decision-making situation. Risk is
there because something may be lost, whether
time, money, effectiveness, or perhaps life
itself, if the wrong decision is made. Uncer-
tainty also exists. Because you do not know
and will never know everything about all
aspects of the situation and have no guaran-
tees that results will be acceptable, you do
not know whether your choice will truly be
the right one; you are uncertain.
A major objective in the decision-making
process is to minimize risk and uncertainty
by learning as much as practical about each
decision-making situation. Because risk and
uncertainty are always present, there is always
the need for judgment in decision making.
Decisions do not make themselves; people
make decisions. All of our efforts at gather-
ing and analyzing information, as well as all
quantitative decision-making techniques, are
no more than efforts to reduce the extent of
pure judgment required in decision making.
For example, 1 of your staff lines up 3 copy
machines for you and asks, ‘‘Which one do
you want to buy?’’ Imagine that you make a
purely judgmental decision by pointing and
saying, ‘‘I’ll take the blue one.’’ The probabil-
ity that you have made the most appropriate
decision is literally one-third, based on a ran-
dom choice of 3 available alternatives, so you
experience a two-thirds chance of being ‘‘wrong.’’
However, if you analyze all the data you can
obtain about the 3 machines and allow your
judgment to be influenced by quantitative
information, although you might never be
absolutely sure you are making the right deci-
sion, you could well reduce the chance of being
wrong to considerably less than two-thirds.
In the last analysis, many decisions will be
right or wrong because of human judgment
regardless of the quantitative information in-
volved. It is not your objective to try to completely
eliminate judgment from decision making; this
cannot be done. Rather, you must refine that
judgment by learning as much as it is practical
to learn about the alternatives.
THE NO-DECISION OPTION
In even the simplest decision-making situa-
tion, there are always at least 2 options: to
decide or not to decide. The no-decision option
is the case in which the latter choice applies. In
effect, what one does is to ‘‘decide not to
decide.’’ This does not have to be a consciously
made decision, but it can, and very often does,
occur by default through procrastination. Tak-
ing no action on a known problem amounts to
the exercise of the no-decision option.
Appreciate that whether the no-decision
option is exercised by choice or through pro-
crastination it is still a decision, and frequently,
it is the decision with the most potentially far-
reaching consequences. All too often, we adopt
an attitude, either consciously or unconsciously,
that suggests, ‘‘If I’m really quiet, maybe it’ll go
away.’’ Sometimes, it does indeed go away and
things get better. However, circumstances usu-
ally do not improve by themselves. To cite one
of the corollaries of the well-known Murphy’s
Law: ‘‘Left unto themselves, things invariably
go from bad to worse.’’
THE MANAGER’S RANGE OF DECISIONS
Decision-making situations may range from
the highly objective (though rarely totally ob-
jective), with plenty of factual information
available, to the purely subjective or totally
judgmental. The decision-making process de-
scribed in the preceding discussion essentially
applies to all decisions; the differences lie in
the kinds of information with which one must
deal in developing alternatives.
It is usually possible to develop a greater de-
gree of comfort with so-called objective decisions.
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https://choiceapplies.In
88 THE HEALTH CARE MANAGER/JANUARY–MARCH 2016
There are facts, figures, and other hard data to
work with. One can compare prices, statistics,
hours, pieces, or other specific indicators and
make choices. Orderly approaches to decision
making are possible, and improved facility at
making such decisions comes with practice in
conscientiously following the steps of the pro-
cess through decision after decision.
The highly subjective decision is a completely
different matter. Little or no data present them-
selves. Choices must be made based on rules
and regulations, policies, procedures, and pre-
cedents and very often on a basic sense of what
is right or wrong, fair or unfair, or logical or
illogical. Many personnel-related decisions fall
in the area of the subjective, and while the
decision-making process does not apply nearly
as specifically as with most objective decisions,
improved decision-making ability again comes
largely through experience.
Although decisions may range from the mostly
objective to the highly subjective, the character
of any particular decision may be influenced by
the conditions under which it must be made.
The single circumstance that probably has the
greatest effect on the character of any particular
decision is the imposition of pressure.
Decision-making pressure is often felt as a
limitation of the time available in which to
investigate properly and render a rational de-
cision. It is one thing to face a situation in
which there is more than adequate time to
develop and assess the workable alternatives.
It becomes another matter entirely when one
realizes that undesirable consequences will re-
sult if a decision is not rendered by a deadline—
and that this deadline does not seem to leave
enough time for reasonable investigation. Un-
fortunately, many managerial decisions are
pressure decisions, and it is necessary to ac-
cept the fact that limited time will force the
decision making into a less-than-desirable
pattern of analysis and action. In this regard,
time may constrain not only the alternatives
but also the entire decision-making process.
RESPONSIBILITY AND AUTHORITY
An anonymous quotation claims, ‘‘It’s all
right to pull decisions out of a hat as long as
you’re wearing it.’’ Although this statement is
only partly true—it is not usually all right to
pull decisions ‘‘out of a hat’’—the point about
responsibility is well made. One who is exercis-
ing the authority to make a decision should of
course be charged with equivalent responsi-
bility. In making decisions for your depart-
ment, you are consistent with your charge as a
manager; you are responsible for the output
and actions of your employees. However, it is
not your place to make a decision with which
employees other than your own or the man-
agers of other departments must comply. In
accepting a given amount of responsibility, you
ordinarily acquire decision-making authority con-
sistent with that responsibility. No manager’s
decisions should exceed the limits of the des-
ignated authority of that person’s position.
THE EFFECTS OF EMOTION
It is all well and good to spell out orderly
steps for the decision-making process and ex-
pect that these will be followed and thus lead
to rational decisions. However, even when the
all of the steps are followed or the decision
maker believes the steps have been followed,
the result is not always a rational decision.
Decision making is not always a completely
rational process; the process and, thus, the
outcomes are frequently affected, perhaps
even governed, by the emotions of the deci-
sion maker.
The 2 principal emotions that seem to
most affect decision making are fear and de-
sire. This is of course an over-simplification in
that human emotion can be experienced as an
incredibly mixed bag of feelings that often
defy specific labels. Yet, the decision maker
who is afraid is often guided at least in part
by that fear, and the decision maker who
personally desires something—who wants to
satisfy a personal need—can similarly and of-
ten unconsciously be diverted from the most
sensible decision.
Guided by fear?
Fear comes into the process in a manner
implied in earlier parts of this article: The
decision maker is afraid of making a mistake.
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Decision Making and Forces That Affect the Process 89
This person is perhaps uneasy concerning
what may be lost if a given decision is wrong,
or perhaps the individual is lacking in self-
confidence or unwilling to accept responsi-
bility. The fearful decision maker is usually
keenly aware of the risks inherent in any
particular decision and is hesitant, sometimes
to the point of paralysis, to decide. The fear-
ful decision maker is often the one who will
‘‘if’’ a problem endlessly and keep gathering
information—subject to what is sometimes
described as analysis paralysis—rather than
take a position and decide.
Often, the fearful decision maker will be a
procrastinator, ignoring the problem or put-
ting off deciding—in effect, exercising the
no-decision option—until 1 of 2 things hap-
pens: the problem goes away on its own (un-
consciously hoped for by the fearful decision
maker) or the matter escalates to a point at which
damage occurs or the issue has become so prom-
inent and potentially harmful that it can no
longer be ignored. Of course, it is not often that
the problem simply goes away, but this seems to
happen often enough to keep some measure
of hope alive for the fearful decision maker.
Driven by desire
Individual wants and needs and personal
desires sometimes channel a decision-making
process toward a conclusion that is less ef-
fective than what might be ideal or most
practical. There will of course be a certain
measure of desire in most decision processes;
often, the desire of the decision maker is to
resolve a problem in a manner that is best for
all concerned, so in this context, desire is
supportive of the process.
REFERENCE
1. McCay JT. The Management of Time. Englewood
Cliffs, NJ: Prentice-Hall, Inc; 1959:77-78.
However, the effects of desire can result in
a suboptimal decision when the decision is
made based largely on what the decision maker
personally wants even though this is not the
best for all concerned or is apparently not the
best available solution to the problem. It is
likely that the decision-related effects of de-
sire are experienced considerably more fre-
quently in personal decisions than in business
decisions, although the realm of organizational
life is not immune to such effects. Consider
the discussion of constraints, especially those
presented by personalities or politics. It is
not unusual for a strong-willed or self-centered
decision maker to decide upon what he or she
wants personally rather than allowing the de-
cision to turn on that which is best for all
concerned.
NO MAGIC FORMULA
It is possible to create valid guidelines for
making many kinds of decisions. This is done
constantly. We generate rules, regulations, poli-
cies, and procedures to guide our decisions.
However, despite of what the occasional ded-
icated bureaucratic leader may believe, it is
not possible to cover all contingencies in ad-
vance and essentially premake all decisions.
It is not possible to cover everything with
remedies that say, in effect, ‘‘When this situa-
tion arises, apply this solution.’’ Good mana-
gerial decisions will remain a matter of arriving
at a proper emphasis on all decision elements
through judgment based on facts and figures,
knowledge, experience, advice, intuition, and
insight.
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