The Health Care Manager

Volume 39, Number 3, pp. 133–141

Copyright © 2020 Wolters Kluwer Health, Inc.
All rights reserved.

DECIDE
A Decision-Making Model for More Effective
Decision Making by Health Care Managers
Kristina L. Guo, PhD, MPH

The purpose of this article is to describe a step-by-step process for decision making, and a model is
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developed to aid health care managers in making more quality decisions, which ultimately determines
the success of organizations. The DECIDE model is the acronym of 6 particular activities needed in the
decision-making process: (1) D = define the problem, (2) E = establish the criteria, (3) C = consider all
the alternatives, (4) I = identify the best alternative, (5) D = develop and implement a plan of action,
and (6) E = evaluate and monitor the solution and feedback when necessary. The DECIDE model is
intended as a resource for health care managers when applying the crucial components of decision
making, and it enables managers to improve their decision-making skills, which leads to more effective
decisions. Key words: decision making, decision model, decision processes, health care manager

EALTH CARE MANAGERS operate in an making is a process of choosing the best alter-
H increasingly complex system. With numer-
ous economic, legal, ethical, organizational, and
native to achieve individual and organizational
objectives. Not all managers know the processes
technical changes taking place, managerial deci- to decision making. Identifying and using the
sion making has a direct impact on individuals in decision-making process help managers to
the workplace and on the performance of the make more effective decisions. Although several
organization and is influenced by a multitude of decision-making models and processes were
other factors that could result in financial success, found in the literature review, this article is differ-
customer satisfaction, and long-term viability for ent because it is intended to add to the existing
the organization. Decision making is inherent research. The purpose of this article is to de-
in all managerial functions and is closely related scribe a step-by-step process for decision mak-
to the planning function. Regardless of level, all ing, and a model is developed to aid managers
managers make decisions, although the decisions in making more quality decisions, which ultimately
made by senior managers have a broader scope, determines the success of organizations. Spe-
affect more individuals, and have a greater impact cifically, an application of the decision-making
than those made by first-line supervisors. Decision model is presented using a health care example,
thus enabling health care managers to improve
their decision-making skills.

Reprinted from Guo KL. DECIDE: A decision-making DECISION-MAKING MODELS

model for more effective decision making by health care
managers. Health Care Manag. 2008:27(2):118-127.
doi: 10.1097/01.HCM.0000285046.27290.90 Several different decision-making processes
and models were found in the literature.1-7 De-
Author Affiliations: Department of Public
Administration, Health Care Administration Program, scriptions and their relevance are discussed here.
University of Hawaii–West Oahu. The basic components of these models are sim-
ilar. For instance, the military model occurs in
Corresponding author: Kristina L. Guo, PhD, MPH,
Department of Public Administration, Health Care 5 steps.1 It begins with defining the objective
Administration Program, University of Hawaii–West in which needs and optimum outcomes are identi-
Oahu, 96-129 Ala Ike, Pearl City, HI 96782 fied. In the second step, all available resources are
([email protected]).
discussed. Third, a plan is established in which a
DOI: 10.1097/HCM.0000000000000299 manager writes down the specific action required.
133

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134 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

The fourth step involves laying out the course of ac- decision making. That is, if managers use an or-
tion so that checkpoints are determined to make ganized and precise process, then the chances
sure that objectives are met. The final step is of more successful and effective decisions will
to provide closure in which accomplished result compared to that of disorganized and
objectives are indicated. This model can be unsystematic processes. This article describes
used to implement decisions; however, spe- a decision-making process using the acronym
cific details are not adequately described. State- DECIDE. Each letter of the acronym DECIDE
ments are ambiguous and lacking in clarity to stands for 1 of 6 specific activities that must be
truly aid managers in making decisions. For in- carried out before proceeding to the next step.
stance, in the last step, “closure is made up of The 6 steps in the DECIDE model is illustrated
those final benchmarks of success” to indicate in Figure 1 and is listed below:
that the plan was successful.2 This statement is 1. D = define the problem.
vague and does not provide managers with di- 2. E = establish the criteria.
rection or adequate information on how to pro- 3. C = consider all the alternatives.
ceed with benchmarking. 4. I = identify the best alternative.
The parliamentary model occurs in 8 steps 5. D = develop and implement a plan of action.
and is similar to the military model. The 8 steps 6. E = evaluate and monitor the solution and
are the following: (1) establish need, (2) define feedback when necessary.
the optimum outcome, (3) conduct a stakeholder To assist managers in making decisions, Figure 2
review, (4) list the pros and cons, (5) make an op- is an application of the DECIDE model using a
tion review, (6) review potential consequences, health care example.
(7) formulate a step-by-step plan, and (8) analyze
achievement.1 D = define the problem
Again, this model does not provide specifics.
For example, in step 7, establishing a plan does Decision making is a problem-solving pro-
not clarify the kinds of information needed for cess that aims to eliminate barriers to achieving
the plan to be successfully implemented. Fur- individual or organizational goals. By defining
thermore, a third decision model combines ele- problems or determining what the barriers are,
ments from both the military and parliamentary then managers can take steps to remove these
models. Known as QUICK, this model focuses barriers. However, defining the problem is not
on quickly making decisions and executing ac- an easy task. It can be a time-consuming process.
tion. It consists of 5 particular activities in the A manager must question the staff and monitor
decision-making process: question appropriate daily activities and tasks to fully investigate the
parties, understand your objectives, investigate extent of the problem. Dunn2 suggests that what
all options, communicate clearly to all concerned, often appears as a problem may only be a symp-
and keep on top of things by monitoring process. tom and digging deeper can lead to the real
However, the QUICK model lacks detail about problem. For example, senior management noted
the specific activities required. Overall, this model that many employees were late to work and
is not comprehensive or well defined. showed negative attitudes toward each other
and the patients. There was increased disagree-
AN ALTERNATIVE MODEL FOR DECISION ment among staff, which caused many to feel
MAKING unhappy in the workplace, and ultimately, they
chose to voluntarily terminate their employ-
After a review of the literature on decision ment at ABC Health Care System. The symptoms
making, this article proceeds to describe an al- showed dissatisfied and unmotivated workers.
ternative decision-making model to help health Upon further investigation, senior management
care managers in the decision-making process. found that the real problem was a lack of com-
A decision-making process consists of a series of munication, supervision, and direction by depart-
steps that managers take to arrive at the decision. ment level managers. As a result, the staff were
The purpose is to create a systematic model for disgruntled, which led to high turnover. To clearly

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 Decision-Making Model for Health Care Managers 135

Figure 1. DECIDE: a model of the decision-making process.

define the real problem, an individual manager to inform patients that renovations and ex-
should be concerned with 3 basic questions: pansions are taking place to better serve
(1) what is the problem? (2) Why should any- patients. Because part of the clinic which
thing be done at all? (3) What should or could houses medical support staff and office
be happening? According to Arnold,3 a deci- equipment is being renovated, the insur-
sion is necessary under these conditions: ance claims specialist along with the copy
1. Something has happened that should not and fax machines that she needs for her
have happened. Thus, corrective action is work were temporarily put in the patient
necessary. For example, all patient med- waiting room. One afternoon, the patient
ical records were inputted into a new registration coordinator was busy with pa-
computer database, and mysteriously, all tients, and the claims specialist was out for
records were lost. The chief information lunch. A patient walked by and saw that a
officer recognizes that a serious problem fax was coming through and fell to the
has occurred, and an action must take place floor. She picked it up and was about to
to correct the error. sit down to read through it. Just then, a
2. Something can happen and should be manager walked by and saw what had
prevented. For instance, at the Summit Am- occurred. He asked for the fax and was
bulatory Surgery Center, signs were posted alarmed when he realized that it detailed

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136 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

Figure 2. An application of the DECIDE model.

confidential patient medical history about aspects and the other responsible for all
one of their celebrity patients. Luckily, the support functions, including registering pa-
patient had not read the confidential infor- tients, confirming patient appointments,
mation. However, it could have caused a and all insurance responsibilities. Dr Scott’s
potential problem had the patient read the wife served as office manager and took care
fax. Although the renovation was only tem- of all other miscellaneous tasks. Two years
porary, problems may occur and must be later, business was going well. Dr Scott felt
prevented from happening. that he needed to hire another physician to
3. Something should happen and is not hap- help him provide more prompt service. As
pening; therefore, it needs to take place. a result, he hired a young medical doctor
When the urgent care clinic opened 2 years who just completed her residency. In the
ago, it began as a small operation, and meantime, the nurse asked for assistance
Dr Scott, owner and the only primary care with clinical responsibilities, and the sup-
physician, hired 1 nurse and 2 assistants, port staff asked for additional help as well.
one responsible for assisting with all clinical Mrs. Scott responded that because of lack

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 Decision-Making Model for Health Care Managers 137

of resources, everyone must do more with organization by knowing one’s subordinates

less. Thus, no additional support staff were and superiors and knowing the business.
going to be hired. In this case, as the clinic Included in the problem definition is an ex-
grows and patient volume increases, some- amination of the purpose or central focus of
thing should happen (hire more support the decision. In other words, the purpose is the
staff) and is not happening (Mrs Scott has mission or needs that must be determined. It
not hired any additional staff). should be stated more broadly to find a wider
Another way to help define a problem is to range of solutions and especially one that is more
develop a statement of the problem. There are tailored to meet one’s needs. For example, a
4 parts to the statement4: manager may wish to establish the best office
1. in what ways (can the problem be addressed), space to accommodate employees with disabil-
2. we (ie, managers, patients, staff) are those ity, establish the best type of work for an indi-
who take ownership of the problem, vidual who is more introverted, or establish the
3. action (implement or make an improve- best way to retain employees in the workplace.
ment), and Arnold3 suggests that the purpose should be
4. response time (goal attainment). formed as follows: “What am I trying to decide
For instance, a problem statement could be and why?” Moreover, statements of purpose
written as follows: “In what ways can we (man- should be opportunity oriented, manageable,
agers) motivate staff to make them more satisfied and positive.9 For instance, Nurse Manager Jones
at work?” Another problem statement could be of the pediatrics department has noticed that
as follows: “In what ways can we (managers) Nurse Adams in the past month has called in
reduce patient waiting times in the emergency sick 3 times and been late 4 times. Before meet-
department?” ing with Adams, Jones tries to establish the pur-
In addition, to define problems, managers pose of her meeting with Adams. Is she trying
can compare status quo against some standard. to establish the best way to ensure that Adams
One standard is using the past against which comes to work on time? That statement is too
managers compare the present to search for narrow; instead, she needs to determine whether
differences. Another way to define problems is Adams is satisfied with her responsibilities as
through plans and forecasts.8 Managers are eval- a nurse and whether she enjoys her current
uated against their organizational goals, such as duties and the work environment. Rather than
achieving and maintaining accreditation status, reprimanding Adams, Jones focuses on finding
lowering complication rates, and increasing pa- out whether Adams is content in the workplace,
tient satisfaction and other performance vari- whether she is getting along with her coworkers,
ables. When these goals fall below projections, or whether she may be having personal issues
then a manager encounters a problem. A third that are affecting her work. Having established
standard is benchmarking to compare against the purpose, Jones works with Adams to deter-
a recognized standard, such as the quality stan- mine the best way to ensure that Adams is happy
dards recognized by the National Committee with her job.
on Quality Assurance. When discrepancies oc- In the decision-making process, the purpose
cur among the 3 standards, then problems exist. is often forgotten. A narrowly focused purpose
McCall and Kaplan8 suggest that recognizing may overlook other opportunities or possibili-
that problems exist is not always an automatic ties and lead to fewer alternatives or solutions.
part of the decision-making process, but this is By defining the problem and the purpose as
an essential function of managers. In fact, effec- broadly as possible, a manager is able to find
tive managers do not spend time dwelling on more significant and far reaching results.
things that could go wrong. Rather, they find
problems and act intuitively to resolve them. E = establish the criteria
The best way to define problems is to gather
information by listening and asking questions After having defined the problem, the second
and also to be knowledgeable about the entire step is to establish the criteria. Criteria are the

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138 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

measures used to arrive at a solution that best On the other hand, a desirable requirement is
fulfills the purpose.3 Criteria should not be a goal that one should aim for and try to
confused with purpose. The purpose is “what achieve but is not a “must.” As a further exam-
needs to be determined and why?” Decision ple, if having a high salary is an absolute crite-
criteria are used to achieve the purpose. Arnold3 rion, then the individual needs to quantify the
uses 3 questions to help establish the criteria. compensation by stating a minimum salary level.
1. What do you want to achieve in your For instance, the absolute criterion would be not
decision? to take a position that offers lower than $50,000
2. What do you want to preserve? a year. In this way, the criteria are first established
3. What do you want to avoid as problems? and then sorted out as absolute requirements
The following is an example of establishing and desirable requirements.
the criteria. David, a first-line supervisor in the
human resources department, is being con- C = consider all the alternatives
sidered for a promotion to the position of a
middle-level management human resources spe- Considering all alternatives is a search for vari-
cialist position. Before accepting the promotion ous alternative courses of actions and solutions.
or deciding to stay in his current position, David Many alternatives, and not just the traditional
clarifies his criteria. He wants to achieve maxi- 2 or 3, need to be considered.10 To derive all
mum earnings, the freedom to work indepen- the alternatives, a manager must engage in brain-
dently, feelings of accomplishment, pleasant work storming to develop and consider as many alter-
environment, appreciation and recognition for natives as possible. This method leads to more
his work, and the opportunity for growth. At choices and increases communication and team
the same time, he hopes to preserve his personal building. Another method to develop alternatives
time for his family, time for friends, and time for is through using the Internet to hold discussion
hobbies (continue to train for the marathon). groups with peers around the world who can ac-
Furthermore, he wants to avoid working with tively participate in discussions by sharing their
unpleasant people, having a high pressure and experiences and outcomes. A major advantage
stressful job, and having a superior who con- of this method is being able to obtain alternatives
stantly looks over his shoulder. After establishing from colleagues from a variety of cultures, which
a list of criteria, David is now clear on what he enriches the alternatives.2 For any given situation,
hopes to achieve, preserve, and avoid. Next, he there should be several alternatives. Although
classifies the criteria by sorting out the more es- these choices are not obvious, a manager is re-
sential and absolute requirements. Not all criteria sponsible for casting a wider net to create as
are equally important. They are separated into many as possible. Some alternatives may not be
categories of relative importance, ranging from desirable. For instance, managers should be aware
high to low. Criteria that receive high values be- that there are certain factors that could limit al-
come more important. In this case, David catego- ternatives, such as authority, human, physical,
rizes his criteria by ranking the most important technological, or economic factors. Specifically,
criterion as achieving the opportunity for per- higher administration or central authority may
sonal growth and advancement within the orga- inform a middle- or first-level manager that a cer-
nization. This is considered more essential for tain alternative is not feasible (ie, central adminis-
David than the other criteria. tration does not support a manager’s alternative
Establishing the criteria means being as spe- to reorganize and combine 2 departments of
cific and precise as possible. This means that dermatology under 1 manager). Human factors
an individual must be able to separate absolute (ie, lack of experienced staff ) may also prevent
requirements from desirable ones. For instance, an the implementation of an alternative. Physical
absolute requirement, or a criterion that must be factors (ie, redesigning the cosmetic surgery
preserved, is one that is unequivocally necessary. clinic) are not physically possible because
If any decision does not satisfy this criterion or re- of space issues. Technological factors (ie, pur-
quirement, then that decision should be rejected. chasing new medical equipment) may not take

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 Decision-Making Model for Health Care Managers 139

precedence this fiscal year. Economic factors Experiential decision making is very common
(ie, recession) may hinder alternatives from be- in medical care. Physicians often base their
ing implemented because costs are much decisions on their experience. A manager can
higher than expected. When evaluating alterna- base his/her decision on a past experience
tives, a manager should identify the economy because of similarities in problem definition.
of the effort, that is, the action that will provide Whatever was held true in the past may still
the greatest benefit with the least amount of effort work in the present situation. Previous experi-
and expenditure.2 In addition to these factors, ence can also be a good defense tactic when
there are other factors that can limit a manager’s identifying an appropriate alternative.2
alternative decisions. For example, legal restric- Intuition or “gut feeling” can help managers
tions, moral and ethical norms, social norms, and choose among alternatives. However, managers
formal organizational policies and rules can pre- should not base their decisions on hunches alone.
vent alternatives from being feasible. Experimentation or testing is a valid approach to
A major factor that determines which alter- aid in identifying the best alternative. For instance,
natives should be chosen is the importance of a manager may want to test different work sched-
organizational values. Managers must abide by ules to accommodate the needs of particular
5 essential values: (1) accountability, (2) adapt- employees. Arnold and Tompkins9 recommend
ability, (3) dependability (4) responsibility, and that the best way to distinguish among the alterna-
(5) visibility.1 First, managers are held account- tives is to place values on the alternatives. In other
able for the decisions they make, how those de- words, similar to step 2 in establishing the criteria,
cisions were determined, and what data were here again, a manager should rank each alterna-
collected and analyzed. Second, in making de- tive against each criterion. An alternative that only
cisions, managers must have a degree of adapt- meets half of the criteria gets a ranking of 5 in re-
ability so that options can be considered and lation to the other alternatives. Once all the alter-
made flexible. Third, employees rely on managers natives have been ranked against the criteria,
to make timely decisions. Fourth, a manager must one can distinguish the more valuable and impor-
be able to take ownership of the decisions. Al- tant alternatives that satisfy more criteria com-
though managers can delegate particular tasks, pared to the others that meet fewer criteria.
they ultimately take responsibility for the out- An alternative that satisfies all the criteria gets
come. Finally, a manager’s visibility is especially the highest rating (ie, a rating of a 10) and be-
crucial in uncertain times and in situations that comes the best alternative. This approach, known
are out of the norm. as maximizing, develops the one best solution
Only when all the factors that may affect a by comparing all the alternatives against all the
set of alternatives are fully considered, then a criteria until one solution emerges. The maxi-
list of feasible alternatives is generated. mizing method leads to the one best solution,
which is the only acceptable one.11
I = identify the best alternative However, when pressured by time, an urgent
solution is needed. In these cases, a set of mini-
In the process of identifying the best alterna- mal criteria is developed, and any alternative that
tive from among the various chosen alternatives, fulfills the minimal criteria is acceptable. This is
a manager should be aware that an alternative de- known as satisficing. Managers recognize that
cision must be of high quality and supported and there may be better solutions, but this simplified
accepted by the group of employees immedi- approach is used because of the urgency of the
ately affected by the decision in the organization. situation to identify any alternative that meets
Decisions would not be effective or may even be the minimal criteria.11
sabotaged when the group does not willingly
accept the decision. D = develop and implement a plan of action
A manager’s final selection of various alterna-
tives is influenced by experience (experiential Developing and implementing a plan of action
decision making), intuition, or experimentation. are as important as making the decision. Planning

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140 THE HEALTH CARE MANAGER/JULY–SEPTEMBER 2020

is the most fundamental function of managers. It to make the decision and is held accountable
provides direction, establishes control, anticipates for the action taken. When pressured to act,
change, and develops responses to uncertainty. managers do not have the luxury of a thorough
This step involves 2 essential processes: commu- examination of all possibilities. Instead, managers
nication and coordination.2,12 Communication may use the shortcut approach and accept the
entails the exchange of information among vari- first alternative that meets the minimal criteria
ous individuals in the organization. If the decision and settle for short-run solutions, such as using
is not clearly communicated to the staff who must the satisficing approach. Quick action relies upon
perform the decision and unless it is coordinated a manager who has the experience and knowl-
with other departments in the organization, the edge in the field and is able to quickly acquire
plan and the decision are worthless. In this step, information to make a decision, analyze the prob-
2 questions must be answered. (1) How is the lem to determine whether quick action is really
action plan going to be implemented? What are needed, break down the problem to identify
the resources used in the actual implementation? which parts need immediate action, consider
Within the planning function, goals and objectives the alternatives by leaving room for change, and
are set. Senior-level administrators are responsible implement the best alternative solution although
for the primary objectives for the organization, he/she knows that there are risks involved. Quick
whereas middle-level managers are responsible action should occur in urgent situations, when
for secondary or department goals. Specifically, problems are simple, fewer people are involved,
they must be able to develop measurable ob- and there is no active conflict. On the other
jectives in the action plan. For instance, the hand, quick action should not be used for more
amount of time and monetary and human re- complex and strategic problems, when multiple
sources devoted to the implementation pro- departments and people are involved in the deci-
cess should be quantified and not left to chance. sion, and there is power struggle.8
A detailed plan of action is necessary to ensure
that the decision has been implemented ac- E = evaluate and monitor the solution
cording to plan.
Decisions are affected by several contextual The final step in the DECIDE model is to eval-
factors, including personal preferences, urgency uate and monitor the solution. It is not enough
of the problem, and the various people involved to just make a decision. It is crucial to evaluate
in the decision-making process.8 Personal pref- the decision made and to investigate “what could
erences, in this case, of a health care manager go wrong.” This step helps to prevent, minimize,
influence the actions that take place. There are and overcome all possible adverse consequences.
different types of managers. Some are cautious For instance, once the decision is made, it may
and prefer to analyze problems carefully, even not work, and then a manager must start over to
routine ones, before taking an action. Others redefine the problem. Feedback is important
are quick to respond to any type of situation. because it provides information related to the
These individual preferences can affect the kind decision. Asking questions from superiors, staff,
of action a problem receives. Another important patients, and other customers are parts of the
contextual factor is urgency. The pressure of feedback process. Through feedback, a manager
impending deadlines results in quick action. finds out whether the decision led to the intended
Quick action consists of 3 characteristics: speed, results. Even if the action has the intended ef-
one-person decision maker, and limited time to fects, unintended consequences may also have
search for information.8 Because managers are occurred. Sometimes, although a decision was
constantly juggling many tasks, the speed for correctly implemented, it does not last forever,
resolving problems is rapid. Quick action often and changes are needed over time, as problems
involves only one person making the decision. recur and new problems arise.
Although a manager may receive input and addi- Part of the evaluation process also involves
tional information from others in the organization, troubleshooting. This consists of 3 basic steps.3
in general, the manager has the formal authority First, list all the possible problems that could

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 Decision-Making Model for Health Care Managers 141

occur. Second, determine the likelihood of each In conclusion, decision making is a skill.
problem occurring and the impact if it does Managers can learn to become better decision
occur, using low, medium, or high possibilities. makers. Effective decision makers require man-
Finally, take preventive action to keep the po- agers to be knowledgeable about themselves
tential problem from occurring. In this way, all and other individuals, as well as possess technical
possible precautions are taken into consider- expertise or industry knowledge. A manager who
ation to assure the success of the decision. knows his/her own weaknesses and strengths
and others’ needs and wants is more likely to
DISCUSSION AND CONCLUSION make a decision that is accepted by others. At
the same time, a decision maker can always ben-
There is no magic or quick fix to decision mak- efit from study and practice. This article has in-
ing. It takes a great deal of skills, knowledge, and troduced ideas and techniques about decision
understanding, all of which take practice and making, and it is intended as a resource to focus
are accumulated over time. Nevertheless, the on the crucial components of decision making
decision-making process and model described to help a manager gain greater understanding
in this article are intended to help managers im- in the art of decision making. Specifically, this
prove their decision making to result in more ef- article has described several scenarios and ex-
fective decisions. By using the DECIDE model, amples based on the health care field to pro-
managers can become better equipped to act mote more skilled managerial decision making
in various situations that require decisions to through the DECIDE model.
be made.

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