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Honing Decision Making Skills

Submitted by?Victor J. Galfano, FACHE

One of the key aspects of leadership is decision making.? As has been written about at great length, the notion of the heroic, lone decision-maker no longer exists (if it ever truly did or was successful over time). However, at the end of the day – leaders are forced to make a final decision.? Situations ranging from choices as strategic as programming or capital investment to critical determinations related to leadership/MD selections and a host of other scenarios.? I recalled an old stats professor who taught us about alpha and beta errors.? (As a reminder – alpha errors are choices you should accept but reject/beta?s being those you should reject but accept).? His position was to forget about the alpha?s – they are gone, nothing you can do about them now.? He said concentrate on your betas – those are the ones you live with.? If you want to test this – think about the last poor hire you made (and we have all made them).

As my most recent role required daily and multiple decisions related to patient selection – I found the need to give some consideration to the entire process, influences and how to maximize those opportunities.


Desiring to get some additional insights, my first stop was a literature review.? I found that Wiser (Sunstein/Hastie 2015), Judgment Calls (Davenport/Manville 2012), Think Again (Finkelstein et al 2008) were very helpful.? These authors provided insights on the wisdom (or lack) of crowds; historic lessons in decision making; the prevalence of pattern recognition and bias in decision making.? All very valuable insights.

I drew the following conclusions.? First, I gained a better understanding of the ?loan warrior? leader as a myth – all the decisions did not need to be made by a single individual and that it was acceptable to trade some nimbleness of decisions for inclusion.? It was clearer that the leader?s role was to set context, shared expectations and objectives to allow the team to participate and have accountability for decisions.? Additionally, patterns and emotional associations while helping us make determinations faster can create bias.? We all look at situations, pick out the similarities and determine a course of action that was felt to be successful the last time we faced this set of circumstances.? However, similarities lead to conclusions that are not always accurate, similarities are stronger than dissimilarities and that it is not always easy to recognize the patterns at work in decision making.? Finally, the value of group decisions can be influenced by unshared knowledge or positions amplified by social reactions.


Based on the ideas gained from the readings and observations over time, a number of approaches evolved.? In my previous role, we had a daily patient review designed to evaluate which patients to accept.? Input was sought from different individuals and functions as to barriers/impacts for a specific course of action.? Historically, input had not been solicited.? At the end, a final choice had to be made, however, now there was greater participation and investment by the team.? Early on, there was surprise and reluctance from some members when opinions were sought, non-committal responses were offered.? Over time – as a more participative approach became more of our practice and pattern, individuals became more comfortable in sharing their perspectives.

Additionally, through discussion, as a team we began to recognize patterns that colored our positions.? We established the need to catalog situations and revisit the long term impact of the decision.? There was a need to expand expertise through additional insights, but also to use objective information to evaluate options and results.? In many instances we made conscious choices and noted that we would monitor the outcome.? In this manner we added to our collective understanding of what were more or less favorable choices.? There was a secondary benefit as we reported back.? We identified that some judgments did not produce the result we wanted, in effect – we made poor beta choices.? It showed that as a team, we were fallible and at the same time could learn.? The approach indicated to the members that there could be misjudgments without personal consequences, as long as we learned.

Finally, it was important for me to draw out participants, get them to share their perspectives and manage my own reactions to avoid reluctance to participate.


In total, the increased frequency and focus of decision making in the post acute setting, helped to better understand and refine some of the skills needed to improve group performance and organizational results.? The take away, is that each context and team is different.? There is a wealth of information out there, the key is to assess and apply what works best in your organization and for your needs.?? The most critical aspect is that we must take the time to evaluate the situation, define the objectives and develop the actions that will address them.

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