Come On, Make a Decision: Practical Tools to Move Beyond an Impasse

October 13, 2009
Chris Cole

Decision-making in medical practices is often stalled by competing interests, conflicting goals and misunderstandings. In this session, you will learn from real-life examples why impasses occur and the problems they create for physicians, staff and patients. You will discover how to gain agreement through using a voting matrix and how to test alternatives and devise voting options. In addition, you will learn the role of confidentiality in protecting future working relationships in the medical practice.

Alan Winkler, MHSA, FACMPE, vice president, clinic operations, St. Vincent Health System, Little Rock, AR

Winkler began his presentation with a review of his objectives for attendees: to identify tactics to create genuine team alignment and agreement, implement tools that clearly delineate options for meeting objectives, clarify the importance of confidentiality and timeframes in decision making.

He next explained that he planned to provide answers to the following questions:

•Why do decision-making impasses occur and what problems do they create inside the practice?

•How do you construct a voting matrix to guide discussion toward a common goal?

•How do you test alternatives (pros/cons) during the discussion phase to make reaching a decision more efficient and effective?

•How do you surface preferences early so time is not wasted?

•How do you devise new options that preserve the best features of existing ones to move the group to agreement?

•What practical tools exist and how do you use them?

Taking a look at why decision making fails, Winkler first looked at advocacy versus inquiry, noting that with advocacy, “we tend to argue our position, fail to consider opposing views, downplay our position’s weaknesses, seek to ‘win’ as opposed to seeking the best solution, and suppress dissension.”

The presenter next provided an example of a problem: One of your practices is not performing well financially and immediate intervention is required, with three alternatives identified: close the practice, convert the practice to an acute care site with mid-levels and only one physician, or sell the practice to a competing entity that has expressed interest. He noted that groups tend to try to reach consensus based on individual preferences. He presented a “voting matrix,” in which each person involved in the decision selects their first, second, and third choice (close, convert, or sell), adding that with this process, no matter what choice is made, one person will be pleased, one person will be disappointed, and one may feel as if his or her concerns weren’t listed to or heeded. “You rarely attain consensus,” Winkler added.

Winkler next presented the “Team Impasse,” with which a team of people look to a leader who is forced into making a decision with individual displeasure as the outcome, or with which the leader looks to the team and then blames them on their indecisiveness, causing the team to resent the leader for acting like a dictator.

So, what approach should one take? Winkler advised that with an inquiry, “we should consider a variety of options, work with others to discover the best solutions, stimulate creative thinking, focus on effective implementation in a timely manner, involve key stakeholders plus individuals who can contribute to and are necessary for the completion of the project, base participation on complementary expertise not on availability or willingness, and utilize people who are willing to make the investment necessary to participate fully in the project.

Focus on the decision-making process first, the speaker advised. He added that a team should be launched with a clear set of responsibilities, with the number of processes under review limited, a clear knowledge of what the non-negotiables are for the group’s work, and an established authority to make the necessary decisions.

Winkler next discussed what he called “The Gallery Walk.” Principles under it include:

•Focus on different aspects of the same problem.

•Rotate small groups from chart to the next, asking them to add / enhance the previous group’s ideas.

•Rank vote, then use a W-W-W format to move action forward.

“Then, once you have narrowed the scope of the issue,” continued Winkler, “set the ground rules.” Require vigorous debate, he added, by asking tough questions, expecting well-reasoned responses, and posing unexpected theoretical questions that force productive thinking. Further, language that triggers defensiveness should be prohibited, natural coalitions should be broken up, and people should be asked to play functional or managerial roles that are different from their own, according to the speaker.

Next, said Winkler, the project must be defined by aligning critical success factors, creating a listing of “must dos” and “must haves,” and asking each person to write his or her 15-word scoping statement, after which the team works through the common themes and words and eliminates duplications and out-of-scope ideas.

Deliverables must also be analyzed, according to the presenter, who stated that the deliverable is NOT the end result of a meandering journey but the end product that insures success. Establish what the deliverable are and clearly set the time table, knowing what is expected, who is responsible, and when it is due, he advised. Also, clearly articulate what outcome you are seeking; in the absence of a goal, he said, participants will choose options based on unspoken premises. “It is essential to keep discussion of the desired outcome distinct from discussion about how to achieve it,” Winkler noted.

Winkler then referred to “The Includes/Excludes Chart,” which can be used in helping come to a consensus on a decisions by determining what decision makers feel the aspects of a certain project, soon-to-be added staff member, etc. should include and not include.

Framing is another important tool in decision making, said Winkler. Once an issue is framed, one can, and should, begin testing alternatives. He noted that most leadership teams are legislatures, with each member representing a significant constituency within an organization, be a business office or nursing. Preferences may surface early, but a problem can exist when others may favor a different solution but remain silent and allow bad decisions to be adopted. The key, said Winkler, is to identify those unspoken alternatives.

Test fences and walls, advised Winkler, adding that “when teams are invited to think about options, they almost immediately focus on what they CAN’T do.” To overcome this, provide a range of options for achieving outcomes and determine your level of influence to effect lasting change,” he said. How do you know your influence? By testing it through test votes. Survey in advance of a meeting to determine areas of agreement and disagreement, how best to frame the problem, and how to eliminate alternatives that are no longer viable, Winkler stated.

Moving on, Winkler noted that “various team members should be made to feel comfortable challenging ideas—not to stall or derail action but to more clearly define both the opportunities and the risks.

Opposing forces (driving and restraining) must also be looked at, said the speaker, without overlooking new options. “Teams should continue to reframe their options in ways that preserve their original intent but also consider new perspectives and approaches,” he added.

In closing, Winkler stated that “True teams make decisions easily and implement plans effectively when they make the journey together.”