Decisions have to be made at every level in practice, from the consulting room to business management, and life in practice is generally smoother if these decisions involve the right people, able to make a high-quality decision in a timely manner.
It has been shown, through recent research on quality improvement in the medical profession, that if we reduce the number of decisions or simplify them, outcomes in terms of effectiveness, patient safety and team well-being improve. For example, using safety checklists before anaesthesia reduces the risk to the patient but also reduces stress for the anaesthetist.
If we reduce the number of decisions or simplify them, outcomes in terms of effectiveness, patient safety and team well-being improve
Common decision-making situations in practice
Imagine this scenario: a vet is mid-consultation but has been asked to speak to a client urgently on the phone. A wrong decision in this situation can upset both team members and clients. If this situation is happening regularly, then a decision should be made to change the practice process so it does not occur other than in an emergency.
Treatment and equipment choices
Vets regularly make choices around treatment options. If these decisions are made during discussions with clients – so that they clearly understand the costs, benefits and potential risks – the risk of misunderstandings, complaints or issues with bill payments will be greatly reduced. Practice leaders must also decide what drugs and vaccines to use routinely. The wrong decision could result in a lack of buy-in from the team, increased vaccine reactions or unnecessary increased costs to the business.
Equipment sometimes breaks in practice, and team leaders (or sometimes the team itself) have to decide what to do. If the wrong decision is made, money and time can be wasted, for instance by replacing equipment repeatedly because the underlying cause (eg incorrect use) is not resolved.
Suggestions and changes
A leader may wish to improve morale and discuss with the team so they feel listened to. Deciding which suggestions to implement is the next important step, so a transparent decision-making process involving the team will give initiatives a greater likelihood of success. Making the wrong decision in the wrong way could have the opposite effect.
Relative ranking and cost–benefit analysis
When it comes to decision making in practice, relative ranking and cost–benefit analysis can be extremely helpful. So, let’s consider the tools that enable a great deal of information about each idea or option to be displayed together, allowing comparisons to be made.
When it comes to decision making in practice, relative ranking and cost–benefit analysis can be extremely helpful
This information is often subjective, and the methods take a little time, making them more useful in business or larger practice decisions than for clinical situations or urgent or simple logistical practice questions.
Decision-making mind maps consider and display each option against its pros and cons, which allows us to consider which has the most pros and the fewest cons, etc.
A futures wheel looks at the impact of each option with knock-on effects considered around the outer circles of the wheel (Figure 1). This encourages us to consider all the effects, not just the desired effects of each option.
I would use these when considering a change or making a decision that has the potential to affect many aspects of the business, such as switching to a new healthcare plan. We would need to consider which plan is clinically superior, the impact a change of plan would have on clients, any training the team would need and what the cost implications would be.
An “impact-versus-difficulty” or “impact-versus-risk” chart is a simpler format of “relative ranking” which ranks options based on ease of implementation, impact and/or risk.
All available options can be plotted on the chart. It is, therefore, easy to pick the options with high positive impact but low risk or lowest barriers to implementation. These charts can also show which options may take more effort or risk but would have a positive impact.
This type of analysis can be done quickly by an individual or a group, so is an efficient way of ranking options – particularly if there are a lot of them!
EMV and decision trees
When a more significant decision with major financial consequences has to be made, it’s important to take a really thorough look by quantifying the costs and benefits (monetary and time).
We can calculate expected monetary value (EMV) by multiplying the likely value of the benefit by its probability and/or multiplying the cost of the potential risk by its probability. This process can be used to create decision trees for your practice (for instance, covering who has authority to purchase what and up to what value).
In clinical cases we use cost–benefit decision making all the time when considering diagnostic and treatment options. We discuss the benefits in terms of relieving suffering and prognosis and the costs in terms of price, time and processes that need to be followed by the veterinary team and the client.
As we must balance several types of cost for each potential benefit and ask clients to decide, we need to use our clinical training to rank them relatively so clients can make an informed decision.
The Eisenhower Matrix helps us prioritise options in terms of urgency and importance (Figure 2):
- Urgent and important things that we need to do straight away
- Important but not urgent things that we can plan to do when we have time
- Urgent but not important tasks can be delegated
- Not important or not urgent tasks can be ignored
This approach can be applied not only to most tasks in practice to help manage stress levels but also to clinical cases to help manage workflow.
Root cause analysis
The root cause analysis technique called “the five whys” is a simple and quick tool to fix problems now and for the future. It can be used as part of a continuous improvement process or in cases where the results we see do not match our expectations (eg when an owner says they are giving the treatment but no effect is seen, so deeper questioning may reveal incorrect dosing).
SWOT analyses are useful for the business side of veterinary practice as they help with understanding the direction a practice should go and whether a particular idea fits with its strengths or plays to its weaknesses. For instance, a reduced-price consultation or vaccination scheme to attract clients may not be useful for a high-cost, high-service-level practice, whereas an offer for a full health check, including several tests, might be.
De Bono’s “six thinking hats”is a great tool to implement during a brainstorming meeting, where each individual’s thoughts about a topic need to be elicited: perhaps, for example, when your team is working out what to do for a local event the practice is supporting or running.
The Vroom-Yetton-Jago tool helps us decide how many people need to be involved in a situation and in what capacity.
Leaders can use this to work out who needs to be involved in a decision if, for example, a team is short staffed and strategies need to be adopted to help them cope. This decision is likely to affect a number of people, and the wrong decision could have a significant impact. While several people may need to be consulted, there is also a time constraint so it might not be a truly collaborative decision.
What decision-making tool should I use?
Many decision-making tools can be helpful in veterinary practice but, for me, the most useful ones are the more simple relative ranking techniques and cost–benefit analyses. I also find the Eisenhower Matrix the most powerful tool for assessing workflow. I use the other tools more infrequently – generally when I am reviewing an aspect of the business as a whole.
By choosing a tool well, time can be saved while simultaneously making better decisions. So, when you are considering which tool to use for which decision, think about:
- The type of decision you have to make
- The effects of a right or wrong decision
- The time you have available
- The people it may affect
With this information, I recommend reviewing the tools available (Table 1) and using them appropriately to increase your effectiveness at work.
|Tools for decision making in veterinary practice||Positives||Negatives||Implications|
|Five whys||Can be simple, quick and effective, thus useable in most situations||Needs good questioning skills and/or good understanding of the problem|
Too many whys can appear aggressive, so may need rephrasing
|Useful in fixing more long-term problems and preventing problems|
Useful in understanding a problem at a deeper level
|SWOT||Provides a rounded picture of the current situation or idea||Just provides background to decision making rather than helping it||Puts internal strengths and weaknesses alongside external opportunities and threats in a grid|
|Six thinking hats||Provides lots of ideas|
Allows and encourages all perspectives in a team while providing balance in the opinions
Uses people’s strengths
No analysis of options except through feelings and emotions (subjective)
|Creates more ideas by looking at the situation from six perspectives (facts and details, imagination, positives, negatives, emotions/feelings and reflection)|
|Vroom-Yetton-Jago||Great at helping make decisions as efficiently as possible while keeping appropriate stakeholders on board||Deciding which people should be involved in decisions and how they should be involved|
Will slow down the decision-making process if a relatively simple decision
|Uses seven questions to establish how important (what quality) the decision is, in what timescale the decision should be made and who should be involved so decides whether the decision should be made autocratically, consultatively or collaboratively for best effect|