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Clinical Decisions Makers
DDBA 8560 - Seminar in Healthcare Managerial Decision Making
Walden University
Clinical Decisions Makers
Decision-making is the process of making a choice between options as to a
course of action (Smith, 2008; Thomas et al., 1991). Clinical decision-making
processes emphasize diagnosis (analyzing a patient’s condition) and predicting how treatment
alternatives will affect the patient. Some clinical decisions are made in time-critical, life-or-death
scenarios. Intensive care units (ICUs) are distinguished by the range of unprecedented events
where there are no clear solutions for the “complex patient” who may have multiple and complex
problems (Weinberger et al., 2013).
Weinberger argued that normal clinical decision making, which combines a
physician’s critical reasoning (formed from previous experience) and the utilization of patient
data, information, and evidence-based literature, is insufficient when dealing with complex
patients. In these time-critical situations, there is insufficient time for information gathering and
Doctors practice medicine and are concerned with promoting or restoring
health and treating impairments (International Labor Organization, 2008). Diagnosis is an
important feature of physician’s skill and capability in medical practice. It is based on the
doctor’s ability to assess the cause of the patient’s condition based on a number of factors such
as the patient’s medical history, physical examination, and medical tests such as the
electrocardiogram and chest x-ray (Hancock, 2012).
Although various models have been proposed to describe the diagnostic process in medical
practice, most agree that it is a central cognitive skill based on both knowledge and judgment
(AMA, 2011). After making a diagnosis, a doctor decides which treatment should be
followed to promote healing. Selecting a treatment includes prescribing the right treatment or
medication, informing patients about risks and alternatives regarding proposed treatment, and
providing adequate follow-up to the patient within a reasonable amount of time. Previous studies
of the doctor’s role in diagnosis and treatment decisions discussed shared decision making
between the patient and doctor, informed consent, and the decision-making process. Charles
(1997) discussed clear methods to define shared decision making including basic characteristics
as well as measurement issues. Charles (1999) described the analytical stages in the treatment
decision-making process and compared shared decision making (both the physician
and patient are involved) to the paternalistic (doctor assumes the dominant role) and informed
decision (information exchange is one way, from physician to patient).
Whitney (2003) used importance and certainty to classify medical choices into six groups; the
levels of importance of medical decisions are minor, routine, important, and major while the
levels of certainty of medical decisions are low, intermediate, and high. A doctor could decide
the level of patient involvement based on these levels. For example, if a doctor feels that a choice
is better but believes other doctors might disagree, then the patient must be involved in the
decision and given a second opinion. Braddock (1997) listed the following, by decreasing
frequency, as some of the types of clinical decisions made by physicians: new medication,
medication renewal, routine diagnostic lab test, and office procedure.
Nurses care for people who are injured, aging, ill, or otherwise impaired.
Their responsibilities include planning and managing care of patients, supervising health care
workers, and working with doctors and others in the practical application of preventive and
curative measures in clinical and community settings (International Labor Organization, 2008).
Previous studies have described different models of the clinical decision-making process. These
models include the information-processing model (nurses used scientific approach and decision
trees), intuitive-humanist model (cue recognition, hypothesis, interpretation and evaluation), and
O’Neill’s clinical decision making model (computerized decision making system) (Banning,
Similarly, Ramezani‐Badr et al. (2009) found that intuition, recognizing similar situations, and
hypothesis testing were the most common reasoning strategies used by nurses. Previous studies
have also organized decision types and categories for nurses. Bucknall (2000) classified their
decisions into intervention, communication, and evaluation categories. For example, an
intervention involved nurse initiating a new therapy, communication involved deciding to check
treatment orders with coworkers, and evaluation involved obtaining test samples to collect
patient information.
Buchbinder and Thompson (2010) organized decision types into the following: Intervention &
effectiveness, Targeting, Prevention, Timing, Referral, Communication, Service organization,
delivery, and management, Assessment, Diagnosis, Information Seeking, and Experimental,
understanding, or hermeneutic. Moreover, the number and types of decisions that nurses face
depend on the work environment, the nurses’ perceptions of their clinical role, their operational
autonomy, and whether or not they see themselves as active influences in the decision-making
process. Bucknall (2003) studied how the nursing landscape (environmental influences) affected
their decision making in critical care settings. He found three main environmental influences:
patient situation, resource availability, and interpersonal relationships. Bucknall acknowledged,
however, that little is known about how these environmental influences affect patient outcomes.
Non-clinical Decision-makers
Non-clinical decisions are administrative in nature. They do not include any
type of medical treatment or testing. For example, medical billers and coders, hospital
executives, and administrative assistants make non-clinical decisions. Although some non-
clinical decision-makers do interact with patients, they do not provide medical care. In this
paper, we focus on the roles of managers and those in positions of authority in the healthcare
system. The first-line manager (also known as a supervisor, administrator, coordinator, or line
manager) is accountable for individuals directly involved with providing medical care. Middle
managers oversee the work of the first-line managers, and they have titles such as general
manager, regional manager, and divisional manager.
Senior-level managers are responsible for organization-wide decisions. These individuals
typically have titles such as president, executive vice president, managing director, chief
operating officer, chief executive officer, or chairperson of the board. A hospital’s board of
directors, or board of trustees, oversees the affairs of hospitals and sets vision and strategic
Healthcare managers are tasked with ensuring the facility runs efficiently.
They are concerned with leading the overall operation of the organization and
ensuring that it moves in a positive direction. They are motivated to “maximize the benefit of the
resources at their disposal for all present and future patients” (Rundall, 2004). They are usually
involved in policy, accounting, and facilities management. The healthcare manager is concerned
with the overall operation of the facility or network and leaves the day-to-day management of
staff to the administrator (Buchbinder, 2010). In this review, we distinguish between senior level
and middle managers.
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