Part III. Leadership in Climate-Related Disaster In 2005, Hurricane Katrina overwhelmed levees and f

Part III. Leadership in Climate-Related Disaster In 2005, Hurricane Katrina overwhelmed levees and flooded the city of New Orleans, Louisiana. This left Charity Hospital, the largest safety-net hospital in the region, without power for five days. Watch this video to hear the experiences of a physician and nurse during those five days: https://youtu.be/AA5B9CJmQjI Scenario: Pretend that you are an APN caring for 10 patients in a medical-surgical unit at Charity Hospital in New Orleans. The hospital loses power, and the back-up generator fails. Read: Grossman (2020) and Sorensen et al. (2020) to guide your responses. APN Role: Considering your APN role as a clinician and a leader, list 3 major areas of concern in the Katrina disaster 10-patient unit scenario. Support your response with evidence (minimum one reference). Decision-Making: Based on the decision-making concepts explained in your textbook (paper book pp. 142-149; e- textbook pp. 333-345), select the decision-making model that you would use in the scenario and explain why. Use the scenario to explain your rationale. Minimum one reference. Decision making models listed in text below Leadership Process: The Dynamic Culture Leadership model (DCL) serves as a guide to healthcare leaders. Select the 3 top elements of the leadership process (DCL) model discussed in your textbook (Chapter 8 figure 8.6) that best apply to the Katrina scenario as if you were leading your team. Explain how you would use each selected element in the scenario. Minimum one reference. Textbook: paper book pp.189-193; e-textbook pp.427-436 Decision-Making and Decision Alignment 19 Decision-making occurs in all organizations. Health organizations, for example, face many decisions each day. The decision-making process begins with identifying a question or problem— that is, an area needing improvement or an operational issue. Problems, issues, questions, and operational challenges come to leaders and managers from many different people, both within and outside the health organization. Acknowledging and accepting the inevitability of decision-making under paradoxical circumstances are necessary to avoid inappropriate reactions; doing so can open the door to alternative solutions. 20 Leaders and managers usually are taught to use the rational decision-making model, which focuses on analytical (quantitative) methods; when necessary, they may couple this approach with group methods (qualitative) such as the normative group technique (brainstorming, alternative categorization, prioritizing alternatives, and selecting an alternative based on group consensus) to triangulate the final result (using both quantitative and qualitative methods) and identify an effective decision. In reality, decision-making is not as sterile and ordered as most have been taught. Both willful choice (rational) decision-making models and reality-based (“garbage can”) models are used in organizations amid a myriad of tools and techniques. Thus there are three major domains of decision-making:Willful choice or rational models Reality-based or garbage can models Combinations of willful choice and reality-based models Likewise, three types of decision-making methods are used: Quantitative methods: Tools such as multiple attribute value, probability-based decision trees, analytical mathematical models, linear programming, and similar tools Qualitative methods: Tools such as focus groups, interviews (formal and informal), normative group techniques, and similar tools Triangulation methods: Combinations of quantitative and qualitative methods where, classically, qualitative methods are perceived as “theory building” and quantitative methods are described as “theory testing, validating, or confirming” A review of bounded rationality, willful choice, and reality-based decision-making models is presented next. More time is spent on reality-based models because this decision-making method is the least well known but may be the most applicable to health organization leaders and managers. Bounded Rationality in Decision-Making Decision-making must occur within the bounded rationality of the environmental context in which the problem must be solved. In modern times, with the advent and availability of the Internet, the bounded rationality of information available for decision-making is immense and global. The bounded rationality for any problem spans the parameters in which the rational resources are available to the decision maker to accomplish positive outcomes. Organizational culture influences decision making as well. As noted in a study of military officers published in 2009, officers with an embedded “forcefulness” and “decisiveness” culture in team leadership roles were more spontaneous and less rational in decision-making than their equally ranked team members. 21 Clearly, then, bounded rationality is influenced by organizational culture. Prior to the dawn of the Information Age and the widespread use of the information was considered to be a scarce resource that was difficult to perception that has changed dramatically, to the point that we live in characterized by “information overload.” Unfortunately, the vast amounts information available do not always include all of the information necessary completely accurate information with which to make the best decisions. Additionally, information may not be in a form that is immediately useable by those who need it. As a result, the most the health leader can hope to achieve is the best decision possible based on the information that is known. With any decision at hand, different levels of ambiguity and uncertainty will surround the issue. Decisions made easily and with little risk tend to have less ambiguity and uncertainty associated with them, whereas complex, difficult, and more risky decisions tend to have much more ambiguity and uncertainty embedded within them. Complicating this feature of human decision-making is the fact that, although much more information is available today, decision makers may not have access to all the proper information regardless of tools available to them. Furthermore, searching out that information may require far more time than decision makers have to arrive at a decision. Not all information or sources will be identifiable, but time will advance in any case. The decision maker will need to arrive at the best decision that can be made at the time. As a consequence, health leaders must often “satisfice” by seeking “a satisfactory reward rather than seeking the maximum reward.” Today’s decision-making models and current understanding imply that decisions are made by rational, intentional, and willful choice. Choice is guided by four basic principles: (1) unambiguous (you know which questions to ask) knowledge of alternatives, (2) probability and knowledge of consequences, (3) a rational and consistent priority system for alternative ordering, and (4) heuristics or decision rules to choose an alternative. 23 These models assume that alternatives are selected based on the greatest utility (via cost-benefit analysis, for example) for the organization, given the environmental situation (e.g., as assessed via a SWOT analysis in strategic planning), and in line with the organization’s objectives, goals, and mission. The decision-making models used in engineering, operations analysis and research, management science, and decision theory represent variations on the rational and willful choice model. 24 The six-step model of decision-making 25 as follows: applies the analytical willful choice model 1. 2. 3. 4. 5. 6. Identify the problem. Collect data. List all possible solutions. Test possible solutions. Select the best course of action. Implement the solution based on the decision made. This practical model assumes that time and information are abundant, energy is available, and goal congruence of participants (everyone is focused on the same set of goals) has been achieved. Criticism of Willful Choice Models Well-known leadership and management concepts consider preplanning (shortand long-term) as the method to solve ambiguity (not knowing what to do) in business. As task complexity increases and time availability decreases, however, the challenge of planning and problem solving becomes increasingly difficult. 26 The rapid pace of operations and change in health care today makes traditionally based organizations less adaptive and flexible in complex environments. 27 Information and time are assumed to be abundant and relatively free resources in rational and willful choice models; moreover, organizational participants in the decision-making process are assumed to have similar (if not the same) goals. 28 Perhaps not surprisingly, these assumptions are the basis of criticisms of the willful choice model. Theories of agency (for conflict management) and economics (scarce resources— namely, time and information) have proposed to resolve contradictory issues associated with individual 30,31 ways. for models, not they economic that greatest good are to 32 This to be in are in the of do mean suggest not use choice models, willful choice as an explanatory model. Both the theories of agency and economics depend on rational participants to validate the models. 29 The reality of the healthcare industry suggests that and group preferences change as underlying variables associated with the decision vary, environmental factors evolve, and other organizational decisions are made. In addition, preferences of participants in the decision-making process often vary in illogical and emotionally dependent Although accounted in the willful choice time and information are considered to be as valuable or scarce in these models as reality actually suggests are. Neoclassical theory suggests the occurs when individuals free pursue self-serving interests. relationship further confounds the underlying assumptions of the willful choice decision-making models. It is unreasonable to assume that each participant in a decision-making process will have similar self-serving goals and similar joint organizational goals most of the time. These contradictions add further credence the view that willful choice models should used when the goals of participants are similar, time and information are available sufficient quantities, and participants well trained use the model. We not to that one should willful but rather that these models should be used in appropriate situations. This leaves the leader and manager in a tough situation: Which model should be used when the willful choice model conditions cannot be met? Other options include reality-based models. In the discussion that follows, the garbage can model is highlighted as an extension of rational decision-making models. It adds to the available methods of decision-making for the leader and manager in health organizations. Reality-Based Decision-Making Models Reality-based models, such as the garbage can model, are intended to extend the understanding of organizational decision-making by emphasizing a temporal context (the situation at one point in time) and accepting chaos as reality. Rational (willful choice) decision-making models are a subset of reality-based models. In ambiguous (do not know what to ask or do) situations where time and information are limited or constrained and “perfect information” is impossible to acquire, where organization structure/hierarchy is loosely coupled, and where the organizational persona seems to embody organized anarchy (chaos), analytical decision-making models do not fit reality. The garbage can model, which was originally designed to reflect decision making in universities, has been cited to explain decision-making processes in various organizations and situations. This kind of model also has been introduced as a possible method for understanding processes such as how an organization learns. 33 For the past two decades, researchers have observed that willful choice models of decision-making underestimate the chaotic nature and complexity characterizing actual decision-making situations; a large percentage of decisions are made by default— that is, when decision-making processes are followed without actually solving anything. 34 Garbage Can Model Concepts Organized bedlam are describe decision-making. occur but more likely to be found under ambiguity and fluid 35 Garbage represent attempts to find logic and order in the midst of decision-making chaos. In this model, garbage— defined as sets of problems, solutions, energy, and participants— is dumped into a can as it is produced (streams of “garbage” in time); when the can is full, a decision is made and removed from the scenario. 36 anarchy , chaos , “Garbage and terms that organizational can decisions in any organization are in ‘organized anarchies,’ where decisions are made involvement of participants.” can models Numerous empirical observations of organizations have confirmed a relatively confusing picture of decision making. Many things seem to be happening at once, technologies are changing and poorly understood; alliances, preferences, and perceptions are changing; solutions, opportunities, ideas, people, and outcomes are mixed together in ways that make interpretation uncertain and leave connections unclear. 37 In arenas in acquisition required ambiguity— not are encountered the 38 the temporal nature of decision-making processes, if taken as “snapshots” in time, would show a sequential arrival of problems, solutions, and information in a complex mix of participants, environmental factors, and consequences of prior decisions as reality in the “organized chaos” of decision-making in organizations. Recognizing that time is not static, and multidimensionality is ever present, the garbage can model depicts the chaotic nature of decision-making through the jumbled mixture of elements in the garbage can. Concepts are uncertain garbage can model. three states are immersed in a The greater the ambiguity of participants (the fewer preferences known, the level uncertainty) and of the organization, and (3) the greater the level of participation (in more specific terms, attention of participants), the more prevalent the garbage can processes in organizational decision-making. Ambiguity is defined as ignorance. Not only does this definition imply lack of management load, speed knowing factors that (and specifically decisions), the decisionmaking in decision-making, uncertainty, and equivocality (i.e., which questions to ask or what to do) commonly influence decision-making process. Thus, grounded in the Originally, three ambiguity technology, that ambiguous and states of nature and, to lesser (2) the more are states of nature for contributed to the model. degree, in uncertainty: diverse the preferences the greater the All (1) of of a lack of ask, information and which of exists and solution the consequences of participation participants in competing time demands battle for to solve a problem a model, (1) fluid (2) 39 the more 40 in of the decisionmaking Loose in sense, defined a more informal, such less on following the yet of is still present. 41 Organizations that are to and shifts in environmental 42- 44 The feedback determines organizational Stronger imply whereas weaker loops loose 45 46 are to determine the coupling it also indicates is available, sets and exists knowledge, but understanding of which questions to which kind connectivity between problem of implementing solutions. Ambiguity when the decision-making process have that attention that would otherwise be necessary (make decision). Because measurement of participation ambiguity depends on many extraneous variables in a sea of limitless situational factors, it is difficult to quantify. Yet attention and energy variations among participants are considered a “given” phenomenon in decision-making processes. Extending the original concepts in the three-factor Takahashi proposed three additional state-of-nature ambiguities to the model: participation, divorce of solutions from discussion, and (3) job performance rather than subjective assessments. Regarding individual preference, Pablo and Sitkin suggest that risk averse a decision maker is, the less tolerant of ambiguity he or she is. Loose coupling organizations fosters adoption garbage can approach. coupling, this is as differentiated focus, that members of the organization focus rules structured connectivity intraorganizational entities Loose coupling tends to allow a more flexible organization. loosely coupled can more readily adapt change factors. strength of the loops present coupling: feedback loops tighter coupling, suggest coupling. Four criteria measured status in organizations: Formal rules: The more closely the rules are followed, the more tightly coupled the organization. (In entrepreneurial organizations, formal rules are not as important.) Agreement on rules: The greater the employee congruence, the tighter the coupling. (Entrepreneurial firms agree on social norms rather than formal rules.) Feedback: The closer the feedback in time, the tighter the coupling. Attention: Empowered individuals allocate energy and time to prioritized projects in their area. (Participation, competence, and empowerment foster focused attention to areas of responsibility.) In the garbage can model, the concept of loose coupling is required to understand decision-making. As a thinking exercise, consider where a health leader should establish the level of coupling in a health organization; refer to Figure 6.1 when contemplating this question. Description Temporal order replaces sequential order. Time is spatial in that a multitude of issues, problems, information flows, and sensing mechanisms can bombard decision makers in short or long-time blocks. How problems and information to resolve the problems arrive in time has relatively equal priority with the evaluation of their importance. Arrival time and sequence in the current context both influence how much attention the decision maker pays to the situation: The process is thoroughly and generally sensitive to load. An increase in the number of problems, relative to the energy available to work on them, makes problems less likely to be solved, decision makers more likely to shift from one arena to another more frequently, and choices longer to make and less likely to resolve problems. 47Individuals in the decision-making process, directly and indirectly, are interconnected and influence the context of the decision at hand. Obviously, attention demands influence decision-making. Time and energy must be allocated to understand, evaluate, and formulate a problem; then to synthesize relevant information; next to evaluate options; and finally, to choose an alternative to counter or terminate the problem. Individuals focus on some things and do not attend to others in the same space of time. Corporate actions, outcomes, and responsiveness are the results of dynamic organizational processes, not heuristics of individual choice. 48 Time and energy combine to form “attention.” Attention is a dynamic concept that is highly dependent on load (i.e., the number of decisions that need to be made). Lending support to the garbage can concept, rational choice in organizational decision-making can be skewed by rituals and symbolism. Symbolic rituals associated with decision-making processes, at times, may derail rational attempts to understand the process. Decision making is a process that reassures the organization that values, norms, and logic are upheld; in this light, decision-making is a ritual. Lastly, decision-making as a process focuses on showing control and logic in a world of complexity and rapid change. Saying, “We made a decision” and “We own the process” implies control of human existence by logical choice. Whatever way the choice ritual makes one feel, decision-making is not rational. For this reason, a depiction of organized chaos rationalized by imperfect participants among a myriad of complex and synergized variables is more appropriate, as shown in Figure 6.2 . Description Decision possibilities in the garbage can run the gamut from willful choice models to garbage can- based models. Decisions by “flight,” “resolution,” and “oversight” are prominent categories in the latter model. Flight is defined as a decision maker’s intentional movement (attention shift) to another area of concern (problem). Resolution comprises a decision that uses classical decision-making processes such as willful choice models. 49 Oversight is defined as decision makers activating a process or procedure before a problem becomes apparent, such as development of a standard operating procedure or use of an established and documented process. Much of the research shows that flight is a significant result of many decision-making processes; in essence, decisions were “overcome by events” or were not made, but rather were allowed to either resolve or escalate themselves. So, what does a leader or manager do to deal with the reality of decision-making? Optimization of Decision-Making If a health organization has decision-making processes that resemble the garbage can environment, understanding the issues and proactively creating an environment that improves decision-making can benefit the organization as a whole. Simulation results as part of garbage can studies revealed that decision-making by resolution is not the most likely result of decision-making processes unless flight results are greatly constrained or decision load is light. Instead, flight and oversight 50 are more likely to occur— that is, either decisions are not made or predetermined and established processes (such as standard operating procedures) are used to a greater degree than might be noted with willful choice models. Given these findings, why not reengineer organizations to foster decision-making based on the goals of the organization, where clearly defined yet challenging goals are set and managers direct subordinates to focus, persist, and provide effort in achieving the goals, 51 comprehend technology, and logically apply rational decision-making processes? The answer is simple: Organizations do not exist to make decisions, but rather to serve the external environment. An organization structured to make decisions will not serve its customers well and eventually will be eliminated from the marketplace. Imperfect decision-making can be expected. In light of the ambiguous reality of information, preference, differences, incongruent goals, and sporadically occurring problems coupled with information bombardment of the temporally “exposed” decision maker, the garbage can model represents a reasonable extension of willful choice theories. Humans strive for processes of willful choice yet, as the garbage can model proposes, fail to achieve rationality in decision-making due to time, energy, attention, uncertainty, ambiguous information, and decision-making load issues. Leaders who can grasp the dynamics of the garbage can are better prepared to position their organizations to make good decisions amid organized chaos and competition. Given this understanding, it seems clear that leaders and managers in health organizations should develop an organizationally sensitive system of decisionmaking with the understanding that decision-making is not always orderly. To do so, they should focus on the following tasks: Evaluating the situation and decisions that need to be made across the organization (or within your area of responsibility) and categorizing decisions by quantity, urgency, information needed to make the decision, and variance in decision outcomes Developing readily available information concerning core business functions Standardizing, documenting, and training team members on decisions that need to be made routinely, where the same or a similar decision outcome is required, and “pushing” those decisions to the lowest levels of the organization as possible but requiring feedback loops Determining decision-making load (quantity in a set time frame) and information available to make decisions for the existing decisions (those not standardized) Determining the importance of a decision to the organization by creating a system of risk determination, prioritization (urgency), and technological requirements for non-standardized decisions Training team members on the decision-making system and processes When a decision or decisions should take the following steps: need to be made, a health organization leader 1. 2. 3. Evaluate the priority and risk of the decision to be made and determine whether this is a standardized decision or a decision that needs to be worked through. Evaluate time and resource availability, participant attention, goals, and incentives. Determine which decision-making method to use: oversight, based on established documented processes such as standard operating procedures; resolution, using a willful choice model; or pushing the decision to the appropriate level, individual, or group. It is also important to know when you do not need to make a decision (flight) based on the importance and risk level of the decision at hand. To develop a reality-based decision-making system, the leader and manager must understand that decision-making is not a sterile and orderly process in most cases. Importantly, organizational decision-making should be aligned (decisions should be in accordance) with the organization’s mission and vision statements and strategic planning- based goals and objectives. Tools of Decision-Making Early careerists need various tools leadership study and Study taking a quantitative and qualitative decision-making tools section highlights quantitative methods, qualitative combination of quantitative and qualitative methods. tool mentioned here (and others not mentioned) be Internet), discussed, practiced, and role-played with organization. Facilitating the decision-making process to be aware of the practice. (e.g., of decision-making for future course) and practice of both are highly recommended. This methods, and triangulation, a It is recommended that each researched (perhaps on the others in the class, group, or in a group or organization is an essential skill of leaders and managers, and a working familiarity tools is a prerequisite to mastering this skill. with decisionmaking Quantitative Methods Quantitative methods include mathematical and computational analytical models to help leaders understand the decision-making situation (data turned into information, which is then turned into knowledge) and produce mathematical outcomes of solutions. Some models are rather simple; others are highly complex. Quantitative models assist in assigning a “number” to uncertainty. Models include multipleattribute value and multiple-utility methods, linear programming, probability, and decision trees based on Bayes’ theorem and can be as complex as discrete and dynamic simulation. In general, simulation uses theoretical distributions and probabilities to “model” the real-world situation on the computer. From this computer model, response variables produce “outcomes” that can be evaluated. Quantitative models take time and understanding of the important elements (also known as factors or variables) associated with the decision that needs to be made. In most health organizations, quantitative models are gaining momentum, though qualified (highly trained and well-practiced) analysts who understand health processes and can perform a range of quantitative analyses remain difficult to find and hire. Even with quantitative analyses in hand, many times leaders and managers skew decisions toward the qualitative side of decision-making. Lean and Six Sigma are two methodologies that are commonly combined into one improvement methodology: Lean Six Sigma (LSS). A later chapter (Chapter 12 in this edition) provides further detail about improvement methodologies. Quantitative methods are critical to Six Sigma, which is a fact-based, data-driven philosophy that follows the Define, Measure, Analyze, Improve, Control (DMAIC) cycle of quality improvement that values defect prevention over detection. 51.5 The Six Sigma technique drives customer satisfaction and bottom-line results by reducing variation and waste and identifying factors critical to quality. It can be applied anywhere variation and waste exist and every employee should be involved in its implementation because quality belongs to everyone. Six Sigma is used to evaluate the capability of a process to perform defect free, where a defect is defined as anything that results in customer dissatisfaction. 53 The higher the Sigma level, the lower the number of defects. At the Six Sigma level, there are approximately 3.4 errors per 1 million opportunities, a virtually error-free rate. 54 Among early adopters of this approach are some of the most highly regarded health systems in the country —the Cleveland Clinic, the Mayo Clinic, and Johns Hopkins Medical Center, to name a few. These facilities consistently rank among the best hospitals in the world. 55 A complementary approach to Six Sigma is Lean. Lean focuses on optimizing systems and processes by removing waste and other non-value-added activities that hinder medical professionals from doing what they do best: providing safe, error-freehealing care to patients. Employees trained in Lean principles are empowered to make improvements in their daily work through standardization and synchronization, thus optimizing healthcare processes to improve quality and the patient experience. 56 The combination of both Lean and Six Sigma (Lean Six Sigma) provides the road map for a thoughtful, sustainable, and continuous improvement culture that leaders have a duty to create and maintain as part of their health mission of their organization. Qualitative Methods Qualitative methods of from personal intuition, discussions with team informal formal interviews, focus groups, nominal group techniques, and even voting. These methods are very useful in the decision-making process because experience, intuition, and common sense can all be used by individuals as well as by groups. Study and practice of qualitative methods are essential for leaders to facilitate decision-making for themselves, groups, and organizations. The most notable leader decision-making tools of a qualitative nature are intuition, consensus, and coalitionbased counsel. include a variety members, tools, ranging interviews, Triangulation The combination of quantitative and qualitative methods results in triangulation, a more thorough (albeit more time-consuming) method with which to make decisions. For example, a group may use nominal group techniques to develop a small set of possible solutions and then analyze each solution quantitatively. From there the leader can make a decision. Training the group or organization to use resolving (“resolution” in reality-based models) used to develop standard operating procedures (“oversight” in reality-based models). Lastly, triangulation can be used to make improvements to processes within the organization. Kaizen theory (discussed later in this chapter) uses triangulation in the context of continuous quality improvement. triangulation is a good practice for decisions. Triangulation can also be Decision-Making in Quality Improvement Extending the into the overall distinct system areas, (2) situational (what to do with assessment implementation, (7) feedback and (8) system, is an organizational culture discussion on decision-making, schema of decision systems. characterized by eight assessment, (3) and information quality integrates In essence, phases: (1) identification of information gathering, to improve), sustainability. Quality improvement, “flag” found in many excellent improvement well quality improvement is a improvement (4) decision-making (5) planning, (6) as a health Ledlow, Gerald (Jerry) R., et al. Leadership for Health Professionals: Theory, Skills, and Applications, Jones & Bartlett Learning, LLC, 2023. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/philau/detail.action?docID=7165144. Created from philau on 2024-11-21 04:59:10.

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