K NNG RA QUYT NH V GII QUYT

KỸ NĂNG RA QUYẾT ĐỊNH VÀ GIẢI QUYẾT VẤN ĐỀ GS, TS, BS LÊ HOÀNG NINH

MỤC TIÊU – Giải quyết vấn đề là gì – Các dạng ra quyết định – Các yếu tố ảnh hưởng đến ra quyết định – Quá trình ra quyết định – Kỷ thuật ra quyết định – Phương pháp giải quyết vấn đề – Các bước trong giải quyết vấn đề – Các yếu tố quyết định trong ra quyết định và giải quyết vấn để

Đại cương • Để đối phó với hệ thống y tế hiện nay đòi hỏi người thầy thuốc phải được chuẩn bị để có những suy nghĩ thấu đáo để có thể ra các quyết định hay giải quyết các vấn đề găp phải trong quá trình công tác • Bất kỳ người quản lý, lãnh đạo nào cũng phải đầu tư suy nghĩ và hành động để giải quyết , ra các quyết định để lãnh đạo cơ quan , đơn vị đạt được mục tiêu cơ quan đơn vị

Ra quyết định là gì • Ra quyết định là tiến trình nhận thức Có Hệ Thống để chọn ra được cái phù hợp nhất, tốt nhất trong các giải pháp khác được đề nghị

Tình huống ra quyết định • Tình huống ra quyết định là bối cảnh mà quyết định được đưa ra. Nó có thể mang tính chất cho cá nhân, hay tình huống lâm sàng, hay một cơ quan , một tổ chức : – Ra quyết định cá nhân : một phần thường gặp trong cuộc sống – Ra quyết định lâm sàng: liên quan đến chất lượng chăm sóc hay vấn đề năng lực chuyên môn – Ra quyết định cơ quan : chọn giải pháp để giải quyết vấn đề của cơ quan đơn vị và đạt đến mục tiêu cơ quan, đơn vị

Sự khác biệt giữa ra quyết định và nói/ thông báo các quyết định

Nói các quyết định (decision talking ) • NÓI CÁC QUYẾT ĐỊNH : – Sự phán quyết được chọn lựa từ hai hay nhiều giải pháp khác nhau. Nó là bước cuối cùng của ra quyết định

Giải quyết vấn đề ( problem solving) • Giải quyết vấn đề : – Là một phần của ra quyết định. Là một tiến trình mang tính hệ thống tập trung trên phân tích tình huống khó khăn, phức tạp. Giải quyết vấn đề luôn bao gồm các bước ra quyết định – Là một tiến trình mà việc chọn lựa ( thế tiến thoái lưỡng nang ) cần được xác định và chỉnh sủa ( is a process whereby a dilemma is identified and corrected )

Giải quyết vấn đề • Vấn đề là gì ? – Là tình trạng hiện không thỏa nhu cần phải thay đổi để đáp ứng với đòi hỏi như mong đợi – Sự khác biệt so với các chuẩn kỳ vọng làm cản trở việt đạt tới mục tiêu của cơ quan

Giải quyết vấn đề • Giải quyết vấn đề và ra quyết định ? : • Many educators use the terms problem solving and decision making synonymously, but there is a small important difference between the two. Although decision making is the last step in the problem solving process, it is possible for decision making to occur without the full analysis required in problem solving. Because problem solving attempts to identify the root problem in situations, much time and energy are spent on identifying the real problem.

Sự liên quan giải quyết vấn đề và ra quyết định Ø Decision making and problem solving used inconsistently or interchangeably. Ø The two process appear similar and may in some instances depend on one another, they are not synonymous. Ø The main distinctions between the two are that decision making may or may not involve a problem, but it involves selection of alternatives. Ø Whereas problem solving involves diagnosis a problem and solving it, which may or may not entail deciding on one correct solution. Ø Most of the time, decision making is a subset of problem solving

Ba dạng chính trong ra quyết định • A. Quyết định thường qui : ( routine decision): – Khi vấn để dễ xác định, phổ biến và đã có luật, chính sách và qui trình thực hiện giúp giải quyết như: thiếu bs trong bệnh viện • B. Quyết định thích nghi ( adaptive decision): – là các quyết định khi vấn đề và giải pháp khác thường. Thí dụ thay đổi giờ và kiểu hình làm việc, cách điểm danh nhân viên. . • C. Quyết định cải cách ( innovative decision) : • Là các quyết định khi vấn đề là bất thường và chưa rõ khi đó cần các giải pháp sáng tạo để giải quyết : thí du : tỷ lệ nhiễm trùng vết mổ lên đến 50 %

Levels of decisions Strategic Administrative Operational

Các cấp độ quyết định 1. Quyết định chiến lược ( strategic decision ): – Quyết định được ra bởi những lãnh đạo về những kế hoạch hoạt động dài hạn. . . – Được gọi là chiến lược do nó tập trung trên các mục tiêu dài hạn của cơ quan đơn vị 2. Quyết định hành chánh ( administrative decision) : thường được ra bởi cán bộ quan lý cấp trung gian ( khoa/ phòng. . . ) : giải quyết những vấn đề bất thường và phát triển các kỹ thuật đễ cải thiện chất lượng công việc

Các cấp độ quyết định • 3. Quyết định vận hành ( operational decision) : là các quyết định thường qui liện quan đến các sự kiện/ biến cố hàng ngày , thường do cán bộ cấp cơ sở ( first line) hay trung gian ra quyết định

Những yếu tố ảnh hưởng đến việc ra quyết định 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Experience and knowledge Creating thinking Self concept Stress Interpersonal conflict Time available, money, energy Routine # non routine decision Risk associated decision Critical nature of work Written guidelines Organization attitude toward decision making Amount and kind information available Degree of acceptance and support Manager personal ability

Decision making process Characteristics of effective decision making process: • • Conducted in a systematic, comprehensive way of thinking. The consequences of the implemented decision are determined. Results in positive outcomes and fewer negative consequences. Based on a "Goal-oriented" analysis of the situation, its problems, and their alternative solutions.

Decision making process

Qui trình ra quyết định (Decision making process) 1) Defining the problem: Bạn phải nói rõ vấn đề , chính xác vấn đề là gì ? Thí dụ Increase Medication errors), you may lack information to define it you can confuse symptoms with underlying causes Prepare a statement of the problem and find someone you trust to review it and to talk it over.

2 - thu thập thông tin từ đâu ? Stakeholders: ”Individuals, groups, organizations that are affected by the problem or its solution”. Facts & data - Results from experimentation and studies. - Interviews of "experts" and trusted sources. - Observed events, past or present, either personally observed. Boundaries The boundaries or constraints of the situation are difficult to change. Opinions and Assumptions Opinions of decision makers, committees or groups, or other powerful groups will be important to the success of your decision. It is important to recognize truth, bias, or prejudice in the opinion.

3) Phát triển các giải pháp (Develop Alternatives) Look at the problems in different ways; find a new perspective that hasn’t thought of before. Once you have listed or mapped alternatives, be open to their possibilities. Make notes on those that: Need more information. Are new solutions. Can be combined or eliminated. Will meet opposition. Seem promising or exciting.

4) Cân nhắc các giải pháp (Weigh Alternatives ) After listing possible alternatives, evaluate them without prejudice, Consider all criteria while a suitable solution may solve the problem, it may not work if resources aren't available, if people won't accept it, or if it causes new problems

5. Select the best alternative Don't consider any alternative as "perfect solution. " If there were, there probably wouldn't be a problem in the first place Consider your intuition, or inner feelings in deciding on a course of action Return to a trusted outsider: Is there something you missed? Does he/she see a problem with your solution? Compromise when you have a full grasp of the problem, and your alternatives

Techniques in weighing alternatives: 1 -Thomas Saaty's Analytical Hierarchy Matrix:

List alternatives in columns and rows as depicted in the matrix above. Starting with Alternative A, go across columns in the matrix and rate each alternative against all the others. When the alternative under consideration has more value than the others. Then give the more valuable alternative a score of 1 When the alternative has less value than the others. Then give the less valuable alternative a score of 0

2 - SFF Matrix: thích hợp, khả thi & mềm dẽo: Suitability Feasibility Flexibility Alternative A Alternative B Alternative C Alternative D Total

A-Suitability: refers to the alternative itself, whether it is ethical or practical. Is it appropriate in scale or importance? An adequate response? Too extreme? B-Feasibility: refers to how many resources will be needed to solve the problem (i. e. Is it affordable? ) How likely will it solve the problem?

C-Flexibility: refers to your ability to respond to unintended consequences, or openness to new possibilities? The alternative itself and whether you can control outcomes once you begin. Total a score for each alternative, compare, prioritize your alternatives. . .

Develop a plan for implementation. Its elements include: Ø Step-by-step process or actions for solving the problem. Ø Communications strategy for notifying stakeholders. Ø Where important or necessary, inform those who care for you and/or will be affected by the change. Prepare them as necessary about your decision. Ø Resource identification/allocation. Ø Timeline for implementation

7) Monitor progress if results are not what you expect, review your options and alternatives Whether or not you achieved your goals, it is important to consider what you have learned from your experience: about yourself, about what you consider important. Lastly, if you have done your best, you have this as one measure of success.

How to improve decision making 1 - interpret data in more than one way. 2 - set criteria of success beforehand. 3 - ask other people 4 - lest your failure 5 - improve feedback by avoid missing and confuse 6 - scrutinize the decision making process 7 - Change your way of deciding and reevaluate your time, and learning from experience 8 - have group do decisions audits too. 9 - be rational.

How to improve decision making? 10 Educate people so they know how to make appropriate decision. 11. Seeking support of top management for decision making at the lowest possible level, (e. g decentralization) 12. Successful manager stay informed about decision being made at different levels of the organization after appropriately delegating these responsibilities. 13. The managers should deal only with these decisions requiring their level of expertise (non routine decisions), support implementation of decisions, and credit the decision maker. 14. Delegation of decision making (routine decision making) to subordinates to gain their trust, loyalty and to raise their selfesteem. 15. Successful manager who is skilled in both decision making and problem solving serves as a motivator and role model for others

PROBLEM - SOLVING PROBLEM SOLVING PROCESS

Traditional Problem-Solving Process The traditional problem-solving model is widely used and is perhaps the most well known of the various models. The seven steps follow. (Decision-making occurs at step 5. ) 1. Identify the problem. 2. Gather data to analyze the causes and consequences of the problem. 3. Explore alternative solutions. 4. Evaluate the alternatives. 5. Select the appropriate solution. 6. Implement the solution. 7. Evaluate the results.

Traditional Problem-Solving Process Although the traditional problem-solving process is an effective model, its weakness lies in : 1. the amount of time needed for proper implementation. This process, therefore, is less effective when time constraints are a consideration. 2. lack of an initial objective-setting step. Setting a decision goal helps to prevent the decision maker from becoming sidetracked.

The Managerial Decision-Making Process The managerial decision-making model, a modified traditional model, eliminates the weakness of the traditional model by adding a goal-setting step. Harrison (1981) has delineated the following steps in the managerial decision-making process: 1. Set objectives. 2. Search for alternatives. 3. Evaluate alternatives. 4. Choose. 5. Implement. 6. Follow up and control.

Decision making techniques vary according to the nature of the problem or topic, decision maker, situation, and decision making method or process. Nurses are using tools such as cause- and- effect diagrams, flow charts, Pareto charts, run charts, histograms, control charts, and scatter diagrams to help understand facts and relationships in processes they are examining.

Decision making techniques 1. Group decision making: A number of studies have shown that professional people do not function well under micromanagement. Group problem solving casts the manager in the role of facilitators and consultant. Compare to individual decision making , group can provide more input and better decision.

Decision making techniques 2. Nominal group technique (NGT) -It is eliciting written questions, ideas, and reactions from group members. Consists of : -Silently generating ideas in written. -Round-robin presentation by group members of their ideas on a flip chart. -Discussing each recorded idea and evaluate. -Voting individually on priority ideas, with group solution being derived mathematically through rank ordering.

Decision making techniques 3. Delphi technique It is judgments on a particular topic are systematically gathered from participants who do not meet face to face. Useful when expert opinions are needed.

Decision making techniques 4. Statistical aggregation: Individuals are polled regarding a specific problem and their responses are tallied. like Delphi technique , does not require a group meeting. no opportunity for group members to strength their interpersonal tie or interaction.

Decision making techniques 5. Brainstorming The idea generating technique wherein a Group members meet and generate diverse ideas about the nature, cause , definition, or solution to a problem without regard to questions of feasibility or practicality. Through this technique, individuals are encouraged to identify a wide range of ideas. Usually, one individual is assigned to record the ideas on a chalkboard. Brainstorming may be used at any stage of the decision- making process, but it is most effective at the beginning, once a problem has been stated.

Decision making techniques 6. fishbone diagram (causes and effect) Is drawn after a brainstorming session, the central problem is visualized as the head of the fish, with the skeleton divided into branches showing contributing causes of different parts of the problem.

Fishbone diagram (Cause and effect) Resources and facilities shortage of physical plant space lack of availability of ground ambulance transportation limited resources of ED in the form of medical Lack of supplies and medications Unavailability of operating room time Ancillary services not same hours as ED No system available for supervising &evaluating work Lack of availability of 24 -hour laboratory tests Increased medical records documentation requirements Increase length of stay due to waiting for test Delay in the services provided by radiology, lab. and ancillary services patient stay in ED Work system ED Overcrowding

7. Thomas Saaty's Analytical Hierarchy Matrix Decision making techniques vary according to the nature of the problem or topic, decision maker, situation, and decision making method or process.

Thomas Saaty's Analytical Hierarchy Matrix List alternatives in columns and rows as depicted in the matrix above. Starting with Alternative A, go across columns in the matrix and rate each alternative against all the others. When the alternative under consideration has more value than the others, Then give the more valuable alternative a score of When the alternative has less value than the others. Then give the less valuable alternative a score of Add the scores for each row/alternative; highest score is the highest rated alternative according to the criteria you used. In the matrix above, Alternative C scores highest, so it's the highest rated alternative.

Problem solving methods: Trial-and-error method : one solution after another is tried until the problem is solved or appears to be improving. Experimentation: a theory is tested to enhance knowledge, understanding , or prediction. Affinity map : a tool used to identify problems.

Steps in problem solving 1 - define the problem 2 - gather information 3 - analyze the information 4 - develop solutions 5 - Make a decision 6 - implement the decision 7 - evaluate the solution

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 1. Define Objectives Clearly : • If a decision lacks a clear objective or if an objective is not consistent with the individual’s or organization’s stated philosophy, a poor-quality decision is likely. Sometimes the problem has been identified but the wrong objectives are set. Problems can be extremely complex and may need multiple objectives (Clancy, 2003).

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 2. Gather Data Carefully: Because decisions are based on knowledge and information available to the problem solver at the time the decision must be made, one must learn how to process and obtain accurate information. The acquisition of information begins with identifying the problem or the occasion for the decision and continues throughout the problem-solving process.

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 2. Gather Data Carefully: Because decisions are based on knowledge and information available to the problem solver at the time the decision must be made, one must learn how to process and obtain accurate information. The acquisition of information begins with identifying the problem or the occasion for the decision and continues throughout the problem-solving process.

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING Questions that should be examined in data gathering are: 1. What is the setting? 2. What is the problem? 3. Where is it a problem? 4. When is it a problem? 5. Who is affected by the problem? 6. Is this your problem or someone else’s problem? 7. What is happening? 8. Why is it happening? What are the causes of the problem? Can the causes be prioritized? 9. What are the basic underlying issues? What are the areas of conflict? 10. What are the consequences of the problem? Which is the most serious?

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 3. Generate Many Alternatives : - When seeking alternatives, individuals need to expand their horizons; the most common trap managers fall into is limiting the borders of their decision frames. - Because everyone thinks uniquely, increasing the number of people working on a problem increases the number of alternatives that can be generated. - Brainstorming is another frequently used technique. The goal in brainstorming is to think of all possible alternatives

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 4. Think Logically : People think illogically primarily in three ways. 1. Overgeneralizing. This type of “crooked” thinking occurs when one believes that because A has a particular characteristic, every other A also has the same characteristic. An example of this thinking is when stereotypical statements are used to justify arguments and decisions. 2. Affirming the consequences. In this type of illogical thinking, one decides that if B is good but he or she is doing A, then A must not be good. For example, if a new method is heralded as the best way to perform a nursing procedure and the nurses on your unit are not using that technique, it is illogical to assume that the technique currently used in your unit is wrong or bad.

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 3. Arguing from analogy. This thinking applies a component that is present in two separate concepts and then states that because A is present in B, then A and B are alike in all respects. An example of this would be to argue that because intuition plays a part in clinical and managerial nursing, then any characteristic present in a good clinical nurse also should be present in a good nurse–manager. However, this is not necessarily true; a good nurse– manager does not necessarily possess all the same skills as a good nurse– clinician.

CRITICAL ELEMENTS IN PROBLEM SOLVING AND DECISION MAKING 5. Choose and Act Decisively : Individuals may become vulnerable at this last point in the problem-solving process and choose to delay acting because they lack the courage to face the consequences of their choices. For example, if managers granted all employees’ requests for days off, they would have to accept the consequences of their decision by dealing with short staffing.

INDIVIDUAL VARIATIONS IN DECISION MAKING Because everyone has different values and life experiences, and each person perceives and thinks differently, different decisions may be made given the same set of circumstances. No discussion of decision making would, therefore, be complete without a careful examination of the role of the individual in decision making

INDIVIDUAL VARIATIONS IN DECISION MAKING • Values • Life experience • Individual preference • Individual ways of thinking and decision making

INDIVIDUAL VARIATIONS IN DECISION MAKING 1. values: Individual decisions are based on each person’s value system. No matter how objective the criteria, value judgments will always play a part in a person’s decision making, either consciously or subconsciously. The alternatives generated and the final choice selected are limited by each person’s value system. Because values also influence perceptions, they invariably influence information gathering, information processing, and final outcome

INDIVIDUAL VARIATIONS IN DECISION MAKING 2. Life Experience: Each person brings to the decision-making task past experiences that include education and decision-making experience. The more mature the person and the broader his or her background, the more alternatives he or she can identify. 3. Individual Preference: With all the alternatives a person considers in decision making, one alternative may be preferred over another. The decision maker, for example, may see certain choices as involving greater personal risk than others and therefore may choose the safer alternative. Physical, economic, and emotional risks, and time and energy expenditures, are types of personal risk and costs involved in decision making.

INDIVIDUAL VARIATIONS IN DECISION MAKING 4. Individual Ways of Thinking and Decision Making : Our way of evaluating information and alternatives on which we base our final decision constitutes a thinking skill. Individuals think differently. Some think systematically—and are often called analytical thinkers— whereas others think intuitively. It is believed that most people have either right- or left-brain hemisphere dominance. Some feel that there is a gender difference in how we think and behave. Rudan’s research (2003) looked at how male and female leaders behaved differently and noted that males and females socialized and communicated differently; males paid much less attention to relationships and resisted being influenced. These differences have the potential to effect decision making.

OVERCOMING INDIVIDUAL VULNERABILITY I DECISION MAKING 1. Values : Overcoming a lack of self-awareness through values clarification decreases confusion. People who understand their personal beliefs and feelings will have a conscious awareness of the values on which their decisions are based. 2. Life experience: a person can do some things to decrease this area of vulnerability: -use available resources, including current research and literature, to gain a fuller understanding of the issues involved. -involve other people, such as experienced colleagues, trusted friends, or superiors, to act as sounding boards and advisors. - analyze decisions later to assess their success.

OVERCOMING INDIVIDUAL VULNERABILITY IN DECISION MAKING 3. Individual Preference : Overcoming this area of vulnerability involves self-awareness, honesty, and risk taking. 4. Individual Ways of Thinking : People who make decisions alone are frequently handicapped because they are not able to understand problems fully or make decisions from both an analytical and intuitive perspective. However, in most organizations, both types of thinkers may be found. Using group process, talking management problems over with others, and developing whole-brain thinking also are methods for ensuring that both intuitive and analytical approaches will be used in solving problems and making decisions. Use of heterogeneous rather than homogeneous groups will usually result in better-quality decision making

DECISION MAKING IN ORGANIZATIONS Since organizations are made up of people with differing values and preferences, there is often conflict in organizational decision dynamics. 1. Effect of Organizational Power on Decision Making Powerful people in organizations are more apt to have decisions made (by themselves or their subordinates) that are congruent with their own preferences and values. On the other hand, people wielding little power in organizations must always consider the preference of the powerful when they make management decisions. Power is frequently part of the decision factor (Good, 2003). In organizations choice is constructed and constrained by many factors, and therefore choice is not equally available to all people.

DECISION MAKING IN ORGANIZATIONS 2. Rational and Administrative Decision Making most managerial decisions were based on a careful, scientific, and objective thought process and managers made decisions in a rational manner. In the late 1940 s, Herbert A. Simon’s classic work revealed that most managers made many decisions that did not fit the objective rationality theory. Simon (1965) delineated two types of management decision makers: the economic man and the administrative man.

Comparing the Economic Man with the Administrative Man Economic Administrative Makes decisions in a very rational manner Makes decisions that are good enough. Has complete knowledge of the problem or decision situation. Because complete knowledge is not possible, knowledge is always fragmented. Has a complete list of possible alternatives. Because consequences of alternatives occur in the future, they are impossible to predict accurately. Has a rational system of ordering preference of alternatives. Usually chooses from among a few alternatives, not all possible ones. Selects the decision that will maximize utility function. The final choice is “satisficing” rather than maximizing.

Summary The decision making process may employ several models: rational or normative, descriptive or bounded rationality, satisfying, and political. Decision making techniques vary according to the problem and the degree of risk and uncertainty in the situation.