Expert answer:Response to discussion post U3R18034
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Decision Making Errors
We have all be in the healthcare field for a while now so we might have seen
doctors make the wrong diagnosis because of one of the below reasons. Jerome
Groopman (2007) mentioned that there are error that are associated with the
physicians attribution errors (listening to someone with bad knowledge),
availability error (reflecting on a recent experience even though it may not have
relevance) , search satisfaction error (not doing a deeper dive to understand if
their solution is best), confirmation bias (sticking with their initial decision),
diagnostic momentum (going with the initial diagnosis and not thinking of
alternatives) and commission bias (not taking the time to understand what is
going on but jumping to another fix) (Kovner, Fine,& D’Aquila, 2009).
Even though the Groopman mentions that the bias is for physician, it also related
to management and leaders. Personally, I have caught myself in several of the
above biases during my career. At time it is hard to realize that our thinking
might be wrong and there might be more relevant knowledge out there that we
are not aware of. As leaders our days are pack with meeting and problems that
we must solve fast. We can get stuck in a rut where we might not want to be
innovative. It is our job to realize it is time to snap out of that feeling and move
past it. Leader must work in collaborative manor to propel our facilities to the
next level.
Reference:
Kovner, A. R., Fine, D. J., & D’Aquila, R. (2009). Evidence-based management in
healthcare. Chicago, Il: Health Administration Press.
PhD, Anthony R. K., David J. Fine, FACHE, and Richard FACHE.
Evidence-Based Management In Healthcare. Health Administration
Press, 2009. VitalBook file.
CHAPTER 6: EVIDENCE-BASED MANAGEMENT
RECONSIDERED: 18 MONTHS LATER
Thomas G. Rundall
Anthony R. Kovner
This is a follow-up to the previous chapter.
Since the publication of our article “Evidence-Based Management Reconsidered” (Kovner
and Rundall 2006) we have continued to discuss the issues it raised. The basic arguments
we brought forth continue to seem valid, and we are pleased to observe the spread of EB
management to the non-health sector through the work of several authors.1 We would like to
continue the dialog here.
In our report, we argued that sustainable progress can occur only when all the strategic,
structural, cultural, and technical organizational dimensions support EB management and
are aligned with each other. We realize that changing fundamental aspects of managers’
work and working styles is difficult, but we were surprised at how much actually needed to
change. We learned that managers typically do not research management issues nor use
research evidence in decision making. However, we found that younger managers may be
more likely to access research evidence because of their facility with electronic databases
and the Web. Why don’t large health systems fund more management research? What
would incent large health systems to support management research and encourage use of
research evidence in decision making? What are the costs and benefits of collecting better
evidence to inform important management decisions?
Apparently, managers (and consultants) do not see the need for management research in
improving quality of care, patient safety, and other aspects of hospital and health system
operations—either because they don’t recognize the need, don’t understand the business
case, or aren’t motivated or expected to use research-based evidence in their decision
making. As EB management proponents, we could strengthen our case by researching what
happens when managers use and do not use EB management.2
In the Frontiers article (see Chapter 5), we suggested a five-step approach to EB
management: (1) formulating the research question; (2) acquiring the relevant research
findings and other types of evidence; (3) assessing the validity, quality, and applicability of
the evidence; (4) presenting the evidence in a way that will make its use in the decision
process likely; and (5) applying the evidence in decision making. Where possible in this
volume, we’ve added a sixth step, evaluating the results.
Other researchers have suggested models that incorporate more or fewer steps in the
managerial decision-making process. For example, Daft and Marcic (2006) suggest six:
recognition of decision requirement, diagnosis and analysis of causes, development of
alternatives, selection of desired alternative, implementation of the selected alternative, and
evaluation and feedback. The Shewhart PDSA Quality Improvement Cycle approach has
four steps: plan, do, study, and act.
Unlike other models, ours is specifically designed to incorporate research evidence in the
decision-making process. The number of specific steps is less important than the spirit of
the EB management approach, which stresses making a good faith effort to examine existing
relevant research, and, when necessary, conducting original research to inform important
decisions.
EB management techniques help managers learn to be diligent and consistent in their
decision making. Although our model makes it appear as if one moves neatly from step to
step, this isn’t the case. The steps simply provide a structure for working on a proposed
management intervention or evaluation. They overlap, and one may have to return to earlier
steps or work on several steps simultaneously as the problem-solving work unfolds.
Flexibility is important. Information gathering occurs in all steps, from problem
identification to implementation of a solution. New information may force a manager to
redefine a problem. Proposed solutions may prove to be unworkable, requiring decision
makers to identify new ones. The EB management process is usually not linear; and, under
certain circumstances, some steps may even be combined, abbreviated, or eliminated, as
demonstrated in several of the case studies later in this book.
The steps of any decision-making process are not completely rational. Managers must
reflect upon the biases they bring to the table in seeking and weighing evidence. In clinical
medicine, perhaps 15 percent of a doctor’s diagnoses may be inaccurate, for reasons not
entirely clear, according to noted physician-author Jerome Groopman (2007). This batting
average certainly applies to management diagnoses as well. In fact, Groopman cites
alarming evidence that the worse radiologists perform, the more convinced they are that
they are right. Misplaced confidence (or at least a persona cultivated to convey confidence)
may characterize managers as well; the danger is that other people, especially subordinates,
will not question the assertions of a supremely confident superior.
Groopman suggests that physicians can easily be led astray by seeing a set of circumstances
from only one perspective. He lists the following types of bias:
• •Attribution error—discrediting data from a “tainted” source
• •Availability error—basing a decision on the most recent experience, even though it bears little
relation to past circumstances
• •Search satisfaction error—stopping the search for an answer as soon as a satisfactory solution is
found
• •Confirmation bias—selecting only the parts of the information that confirm an initial judgment
• •Diagnostic momentum—being unable to change one’s mind about a diagnosis, despite
considerable uncertainty
• •Commission bias—“doing something” rather than nothing, even if the evidence says sit tight
Inattention and hurry take over for managers as well as for physicians, and many managers
do not routinely think through such potential cognitive pitfalls. Groopman urges that
physicians recognize and understand their own biases as they approach a decision. He also
encourages patients to speak up with physicians. We offer similar advice to managers,
particularly those with less experience, who must speak up and be encouraged to do so by
senior managers.
Some colleagues argue that EB management appears to be an attempt to breathe new life
into the classical/rational approach to decision making, which has been rejected by many
scholars as too prescriptive and not applicable in most real-world decision-making
situations. We recognize that there are many ways to conceptualize organizational decision
making. The classical/rational perspective is prescriptive, and recent organizational
scholarship suggests that there is a good deal of real-world use of the approach, particularly
for routine organizational decisions.
Other perspectives on decision making, such as the administrative and political
perspectives, are more descriptive and de-emphasize the role of research evidence in
decision making. We believe that regardless of the decision-making perspective one is using,
the use of better evidence, admittedly at a cost, can improve the decision.
Like all decision-making tools (e.g., Pareto analysis, decision trees, force-field analysis,
linear programming), the EB management process is prescriptive, inasmuch as it describes
activities and tasks that must be performed in order to achieve a desired objective. If a
manager wants to use evidence in a decision-making process, the EB management model
provides a useful framework for thinking through and doing the necessary tasks. It does not
prescribe the kind of evidence, how to obtain it, or what decisions should be made. As
readers will observe in the case studies, “evidence” covers a lot of intellectual territory.
Many healthcare managers reacted to our article with some mixture of enthusiasm and
uncertainty. Some said, essentially, “I like what you wrote, and I like the idea of EB
management, but how much of this should I implement, in what ways, in my organization?”
We did not and cannot offer precise answers to such questions. We do suggest that these
managers spend some more time focusing on their strategic decision-making process—
developing structures that establish accountability for using an EB management approach,
building a questioning culture, and improving the training of the managerial workforce in
applying the EB management approach.
With experience, best practices will emerge, and we will need mechanisms for sharing them.
One such mechanism already in place is an EB management website (http://evidencebasedmanagement.com), which includes a blog through which managers can share
experiences.
Finally, we hypothesize that healthcare managers who make decisions based on better
evidence work in organizations that, in the long run, will be shown to provide better patient
care and achieve better outcomes. We have presented many examples in the case studies in
this text to justify this hypothesis. The evidence in support increases every month.
Improving quality and patient safety are two of the most important goals of healthcare
organizations (organizational sustainability is a third). Efforts to achieve these goals are
likely to be more effective and less expensive if they are informed by strong research
evidence.
Endnotes
1.See, for example, Rousseau, D. M., and S. McCarthy, “Evidence-Based Management:
Educating Managers from an Evidence-Based Perspective.” Academy of Management Learning
and Education 6 (1): 84–101; Pfeffer, J. and R. I. Sutton, Hard Facts, Dangerous Half-Truths
and Total Nonsense: Profiting from Evidence-Based Management. Boston: Harvard Business
School Press, 2006; and, in a related vein, Davenport, T. H., and J. G. Harris, Competing on
Analytics. Boston: Harvard Business School Press, 2007.
2.We have tried and failed in trying to get funding for most of our management research projects.
References
Daft, R. L., and D. Marcic. 2006. Understanding Management, 5th edition. Mason, OH:
Thompson-Southwestern.
Groopman, J. 2007. How Doctors Think. Boston: Houghton-Mifflin.
Kovner, A. R., and T. G. Rundall. 2006. “Evidence-Based Management
Reconsidered.” Frontiers of Health Services Management 22: 3–22.
(PhD 79-82)
PhD, Anthony R. K., David J. Fine, FACHE, and Richard FACHE. Evidence-Based
Management In Healthcare. Health Administration Press, 2009. VitalBook file.
…
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