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 decision 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 ([email protected]).

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

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

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

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 …