Strong Central Authority

John Smith was transported by emergency ambulance to the Emergency Department of County General Hospital, a Level I Trauma Center. He had suffered multiple gunshots to his chest. He was rapidly wheeled into Trauma Room #1, where he was assessed by Roy Chapman, MD, a trauma surgeon and head of the trauma team that evening. A nurse measured Mr. Smith’s blood pressure and pulse. A technician applied electrocardiographic electrodes to Mr. Smith’s chest. Mr. Smith’s blood pressure was low, and his pulse was rapid. A quick physical examination revealed that he was unconscious and bleeding from 2 gunshot wounds, one in the center of his chest and one on the left side. Within 3 minutes, Dr. Chapman ordered administration of intravenous fluid at a rapid rate as well as transfusions of red blood cells, fresh frozen plasma, and platelets to control bleeding. Dr. Chapman suspected that Mr. Smith’s aorta had been perforated by a bullet. Within a few more minutes, Mr. Smith was taken to the operating room.

This vignette illustrates team decision making by strong central authority. Although input from various professionals was relevant to the decision, time did not permit a decision based on deliberation by the team. The structure of the trauma team provided for strong authority vested in the leader, who on the evening in question was Dr. Chapman. If the leader is well informed and has good judgment, action proceeds rapidly and effectively. This approach to team decision making is often described as autocratic or military, and it is appropriate in situations of high risk in which rapid action is required to achieve desirable results or to avoid serious adverse outcomes. In health care, use of this model is not common. The number of acute emergency team decisions is a tiny portion of the team decisions made daily in clinical settings. Although vignettes about decision making by strong central authority are easily understood and often cited as examples of admirable team leadership, they are actually unusual. Decision making by strong central authority does not serve well as a general paradigm in health care even though it is entirely appropriate in some situations.

Some effective teams use strong central authority for making decisions even though time would allow for discussion and joint decision making by team members. Decisions that are regarded as trivial by team members can be handled efficiently by central authority without consultation. For example, deciding on the color of a replacement carpet is seldom a matter calling for input from all the team members. In other cases, the leader may seek consultation with one or several team members before making a decision using his or her own authority. Many healthcare administrative leadership teams function in this way.

Voting

Riverside Heart Clinic was introduced in Chapter 6. Twelve cardiologists and 5 NPs practiced at Riverside Heart. About 4 years ago, nearly all of them came to acknowledge that they had a problem with scheduling vacations. Although the cardiologists and nurse practitioners (NPs) were ready and willing to cover for their absent colleagues in the clinic and at the 2 hospitals they used, sometimes there were too few cardiologists and NPs in town to see all the patients who needed care. On these occasions, in the clinic the cardiologists and NPs would triple-book appointments (schedule 3 patients at the same time). Patients often waited 2-3 hours to see the clinicians with whom they had appointments. Cardiologists also would dash from one hospital to the other to perform catheterizations that were tightly scheduled even though they were scheduled at different hospitals.

The group called a special meeting of all 22 practitioners, chaired by Sam Lawrence, MD, the senior cardiologist in the group. Nineteen attended. No explanation of the problem was needed because everyone understood the issue. Dr. Lawrence explained that he and 2 others had met and devised 3 possible solutions for their consideration: (1) separately limit the number of cardiologists and NPs who could be gone at any one time and have everyone sign up on a master calendar on a first-come-first-serve basis, (2) set a date for vacation requests to be submitted for the coming year and then draw lots for those weeks requested by more people than the number of people permitted to be gone, (3) use option 1 but set aside the Christmas-New Year period and possibly other particularly popular times to be handled with a rotation in 3-year cycles instead of using the first-come-first-serve method. Dr. Lawrence was not manipulating the situation. He genuinely wanted a solution to a problem that had become a point of distress for many people in the practice, and he did not have a favorite solution.

Dr. Lawrence invited everyone at the meeting to propose additional options for solving the problem. However, none were proposed, and this was not surprising since no one except Dr. Lawrence knew in advance what would happen at the meeting because Dr. Lawrence had not thought to tell anyone. Dr. Lawrence told the group that they would have ample time to discuss the options and would then vote unless they had reached general agreement through discussion. There followed a 90-minute, heated discussion of the 3 alternatives, including many suggestions for modifications of all 3. Eventually, it became clear to Dr. Lawrence—and everyone else—that agreement would not be reached. He then called for a vote. There were 9 votes for option 1, 6 votes for option 2, and 4 votes for option 3. Wanting a majority decision, Dr. Lawrence then deleted option 3 and asked the group to vote again. Thirteen people voted for option 1 and 6 people for option 2. Dr. Lawrence announced the result and said that vacations would be scheduled in accordance with option 1 as soon as further details had been settled by him and Riverside Heart’s 2 office managers.

The 6 members of the group who had voted for option 2 left the room angry. In addition, 5 of the 13 who had voted for option 1 left annoyed because they preferred one or another variant of option 1.

Voting is an alternative to decision making by strong central authority. Sometimes it works well, but often it does not. In the case of the team management decision made at Riverside Heart, a majority of the team left the room dissatisfied; this did not auger well for the implementation of the scheduling process that had been chosen.

There are many different rules that can be used to come to a decision by voting (Thompson, 2011, pp. 157-158). For example, each voter can be asked to rate each option on a scale, say, of 1 to 10. The ratings can then be averaged across all voters, and the option with the highest average rating is declared the winner. Or, the option with the highest median rating can be declared the winner. More commonly, voters are asked to vote for the option they prefer without weighting the options, and the option that wins a plurality of votes is regarded as the winner. The plurality of votes is the highest vote total, regardless of whether that number is a majority of the votes cast, that is, regardless of whether that number is more than half of the votes. Plurality rule is used in almost all US elections and is often used by teams. In the meeting at Riverside Heart, Dr. Lawrence stipulated that the group would use majority rule rather than plurality rule, and so he deleted the option with the fewest votes on the first ballot and had the group vote again, thereby assuring that one of the options would receive a majority of the votes. This rule is also often used when teams vote. Majority rule and plurality rule generally perform quite well in reaching decisions that later can be assessed against some objective standard, for example, when groups choose among proposed solutions to problems and those solutions are later tested to determine whether they were successful (Hastie and Kameda, 2005). Of course, not all group decisions can be evaluated in this way since some decisions concern matters of personal preference—for which there is no standard available to use in testing the soundness or accuracy of the group’s decision. Nonetheless, there is no need to use decision rules for voting that are more complicated than plurality rule and majority rule, except in very unusual situations.

Despite their strengths, majority rule and plurality rule have several disadvantages in team decision making. For example, neither procedure takes account of the strength of conviction among those who are voting. A vote backed with passion counts the same as a vote from someone who is almost indifferent. Thus the majority may consist mainly of people who care little about the choice at hand while a minority cares deeply. A result of this kind is likely to cause resentment and difficulties later on. Voting tends to polarize the team and interfere with negotiation to reach a compromise that might yield a solution acceptable to a larger number of people than a simple plurality or a majority. At the meeting at Riverside Heart, the team might have been able to work through variations on options 1-3 and arrive at a more broadly supported solution if they had not thought they were headed toward a vote at the end of the discussion. Also, since voting does not encourage collaborative interaction to construct new options, it does not foster support for the decision that is ultimately made. Voting can provide a quick route to a decision, but it often has significant longer-term ill effects.

On the other hand, voting does have a very useful role in team decision making. It is a rapid, simple method for deciding issues in which no one in the team is heavily invested. For example, the choice of the restaurant for a holiday gathering is sometimes a matter in which team members want to have a say although commonly no one is heavily invested in any particular outcome. In this kind of situation, 3 choices can be put forward and a quick vote taken.

Incidentally, voting does have a central and valuable role in groups that are not teams, specifically, in groups that consist of competitors, for example, hospital Chief Executive Officers (CEOs) gathered at a hospital association meeting. In this type of setting, making decisions by common agreement is often much slower than making decisions by voting, and the effort to reach agreement risks generating interpersonal conflict and frustration rather than support for the decision made (Tjosvold and Field, 1983). In situations in which the participants do not share a common goal but do share some interests, voting is ordinarily superior to other methods for group decision making.

Unanimous Agreement

Instead of guiding Riverside Heart’s cardiologists and NPs to a majority vote, Dr. Lawrence could have stated at the outset that the group would make its decision by agreement across the whole group present, that is, by unanimous agreement. This is a third model for team decision making.

Using unanimous agreement as the basis for the team’s choice forces the team members to listen to each other and work through various alternatives to a proposal that everyone endorses. This process tends to produce a decision that is widely approved while it simultaneously builds support for the implementation of that decision.

The disadvantage of requiring unanimous agreement for decisions, of course, is that the team may not be able to make a decision. Suppose, for example, that Dr. Lawrence had required the group to achieve unanimous agreement on its decision about vacation schedules. Under this scenario, one or more members of the group who did not celebrate Christmas might have objected to treating Christmas week differently from other portions of the year. And similarly, members who celebrated Christmas might have felt strongly that Christmas week should be handled in a manner that assured anyone interested in vacationing during that week that she or he would be able to do so at least every 3-4 years. Under these circumstances, unanimous agreement would have been impossible. Requiring every member of the team positively to affirm the final decision is a very demanding rule for decision making, and it can easily result in time-consuming negotiations or in stalemate. Nonetheless, when strong support for a decision is needed to assure durable commitment for its implementation, requiring unanimous agreement can be entirely appropriate.

Consensus

The pitfalls of voting and of decision by unanimous agreement can be avoided by relaxing the standard of unanimous agreement just a bit. Instead of requiring that all team members positively affirm the choice made, one can require only that every member be willing to accept the choice made or “live with it.” We use the term consensus for agreement by general acceptance rather than by positive affirmation, and we distinguish between decision by consensus and decision by unanimous agreement.

For example, suppose Dr. Lawrence had proposed that Riverside Heart’s clinicians decide how to handle scheduling vacations by basing the decision on consensus as defined here. As the 90 minutes of discussion progressed, someone wanting to be assured of a Christmas-week vacation at least every 3-4 years might have proposed rotating the people who can take vacation during this week only to find that she or he was opposed by someone who had no special interest in this week but did wish to be absent for Rosh Hashanah as often as possible (or someone who wished to be absent as often as possible for the end of Ramadan or for some other favored week during the year). At that point, someone in the group might propose that each person could designate one and only one of these especially popular times as his or her “prime vacation time.” All of those choosing Christmas week as their prime vacation time would participate in a rotation, those choosing Rosh Hashanah would participate in a separate rotation, and so on—regardless of their religion or lack of religion or any other basis for choosing a particular period as their prime vacation times. This arrangement would imply that those choosing Christmas week could never be absent on Rosh Hashanah, those choosing Rosh Hashanah could never be absent during Christmas week, and so on. Everyone would gain something by this arrangement, but everyone would also lose flexibility. Some members might be quite annoyed by the loss of flexibility although willing to accept it because they would be assured of a vacation during their prime vacation time at least every 3-4 years. Under these circumstances, there might well be some people who would not positively affirm the proposal even though they could accept it. So, if Dr. Lawrence were to test for consensus by asking whether everyone could “live with this,” it might happen that agreement was present throughout the room even though the enthusiasm associated with unanimous agreement was not present. Decision by consensus can permit the team to make a decision and move ahead when requiring unanimous agreement would result in an impasse.

An important reason that consensus is easier to achieve than unanimous agreement is that consensus permits team members to say that they oppose the choice made even though they also say that they will accept it. There may be several reasons for a team member to acquiesce in this way, for example, a desire to support the group in coming to a decision instead of getting stuck, an expectation of future consideration when some other difficult choice is faced, or a desire to return the team’s favor of considerate treatment sometime in the past.

Using consensus decision making often requires some preparation prior to having the team make a decision. In the case of Riverside Heart, it would have been useful for a small group of, say, 4-5 people to talk through options and discover what conflicts and compromises might be anticipated and then present 2-4 thoughtful options to the group instead of expecting that a workable compromise might be constructed in the heat of discussion in the large group.

Choosing a Method for Making Decisions

Different situations call for different methods of team decision making. For example, situations of extreme urgency and high risk call for decision by strong central authority as in the case of the emergency room team treating a gunshot victim. Voting is suitable for a choice among alternatives that are all more or less acceptable to all team members.

However, most healthcare teams repeatedly use the same method for most of their decisions. Emergency room teams and other clinical template teams usually use decision making by strong central authority because they generally function under circumstances of moderate to high urgency. In the operating room, surgeons exercise central authority in making decisions—although this authority passes to the anesthesiologist for certain decisions. In rare situations of high urgency in matters of public relations, the CEO of a hospital may exercise similar authority. In contrast, most true teams prefer to make decisions by consensus, routinely avoiding voting. This choice is based on a desire to avoid conflicts and to generate broad support for decisions even though this desire is usually not stated explicitly and is often not even fully conscious among the team members and leaders.

Decisions in clinical knotworks (see Chapter 2) are sometimes problematic for 2 reasons. First, it is often unclear whether the members of a knotwork are functioning as a team or not. The referring physician, oncologist, and radiation oncologist treating a patient with pancreatic cancer may see themselves as a team, or they may see themselves as individual physicians practicing in their separate specialties. If they see themselves as individual physicians, they will construe all decisions to be made as individual clinical decisions and give no thought to how team clinical decisions should be made. If some members of the knotwork conceive of the knotwork as a team, they will see other members who operate autonomously as usurping the authority of the whole team, and conflict will result. Second, even if the knotwork members do think of themselves as a team, the question of how decisions will be made is often not raised. Sometimes one of the team members, for example, the oncologist, assumes that he or she has decision-making authority for all decisions except those requiring expertise outside of his or her field, for example, decisions about the dose and timing of radiation therapy. At the same time, the referring family physician may have the same (unstated) assumption, resulting in conflicts and inadequate communication from the point of view of both the oncologist and the family physician. The best approach to avoiding these difficulties is to address at the outset the questions of whether there is a team at work and, if so, how communication and decision making will be handled. Unfortunately, it is common for physicians and other clinicians not to be conversant with teamwork concepts, and so addressing these questions is often difficult.

At times, a team will change from using its customary decision-making method to using a different method. A team that ordinarily uses consensus will sometimes need to switch to requiring unanimous agreement. This change is appropriate when ill effects or high risk for some team members will result from one or more of the choices being considered. In the vignette about Riverside Heart, Dr. Lawrence was attempting to guide the team in its method for decision making although he did not succeed very well. The team often used voting with plurality rule for making decisions. As the voting progressed, he changed the basis for decision making from plurality rule to majority rule. Most likely the team would have fared better using consensus.

An interesting historical example of a shift from the extreme of decision by central authority to the opposite extreme of decision by unanimous agreement occurred when Hernán Cortés and his captains considered whether to burn their ships on the east coast of Mexico when beginning the conquest of the Aztec Empire in 1519. Burning the ships eliminated retreat as an option for Cortés’ army, thus spurring on the soldiers. On the other hand, the risk for everyone in the group rose dramatically. Cortés was accustomed to making decisions on the strength of his own authority, with or without conferring with trusted captains. In addressing the question of burning the ships, however, he used his authority to pass the decision entirely to his captains (Díaz, 1963, p. 130). This action was suitable under the circumstances and provided a brilliant means for securing the support of his captains for burning the ships. Of course, he took the risk that they might have decided not to burn the ships.

The method used for making decisions in a healthcare team often is based either on expectations generated through professional acculturation during training or on long-established precedent in a given team. Physicians usually make decisions in groups of their peers by consensus or by voting because the culture of physicians is individualistic and egalitarian. Nurses working in hospitals or other institutions commonly make decisions by central authority but only after consultation within the team. The culture of nursing is both hierarchical and collegial. Healthcare administrative teams usually seek consensus but are prepared to use central authority if consensus cannot be achieved swiftly. The culture of healthcare administration is hierarchical. Regardless of the effects of professional culture, the method used in any particular team almost always varies in response to the nature of the issue to be decided and the context.

One of the responsibilities of the leader is to attend to how decisions are being made and to assess whether the method used for a particular decision meets the team’s needs for reaching its goal and for development and maintenance of the team’s capacity to function well over time. If leaders have strong authority, they can alter the method of decision making as they see fit as in the case of Cortés and his captains. Similarly, Dr. Lawrence at Riverside Heart Clinic, while not an autocrat, also had sufficient standing in the group to be able to specify how the decision about vacation scheduling would be made. However, if a team is long accustomed to decision making by consensus, ordinarily a switch to the use of strong central authority or to voting cannot simply be stipulated by the leader. In effect, the leader will need to seek broad approval from the group for the change. In these cases, the leader will usually propose the switch and then watch to see whether there are objections, rarely explicitly seeking formal action to confirm the switch that is proposed. Changing from consensus decision making to the use of unanimous agreement is more easily achieved because the methods are similar.

DECISION-MAKING PITFALLS AND THEIR SOLUTIONS

Some pitfalls in group decision making are discussed in Chapter 6 under the more general heading Hazards for Teams. In that chapter, suppression of dissent and novel ideas is discussed as well as reaching consensus prematurely, for example, because of the overwhelming influence of one person in the group. In this chapter, we consider additional pitfalls for teams making decisions. A list of pitfalls is shown in Table 9–2.

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