Welcome to ISQua Login | Register | Contact Us

ISQua Fellowship Forum

Leadership and Organizational Decision-making

Phil Hassen, President of the Canadian Network for International Surgery; ISQua Fellowship Forum Moderator.


February 2016

Over the span of my career, it has been suggested to me that effective decision-making is more important to organizational success than strategic planning, and furthermore that building consensus around a common set of values for running an organization is an essential leadership behavior (See authors J. Kouzes and B. Posner).  In a concerted effort to accomplish quality and safety goals and to ensure organizational effectiveness and efficiency, there is no doubt that healthcare leaders are making daily decisions or facilitating others to make decisions in a complex health care system. Given the organizational dynamics and ever-changing complexity characterized by many parts functioning concurrently; and given the interaction of interdisciplinary professionals, it is inevitable that decision-making is difficult and becomes itself more complex with significant consequences.

The development of leadership skills and competencies, is intertwined with the development of leadership values and principles about how to make the best, timely decisions in a way which engages individuals and teams.  Most importantly effective decision-making processes requires having a clear understanding of organizational goals and objectives as well as role clarity with respect to who is responsible for what  decisions.  Fundamentally, strong individual and team decision-making processes is a reflection of an effective leader.

Effective decision-making by leaders must consider the organizations –

  • Vision
  • Goals
  • Values

as well as the parameters of the decision and metrics to assess whether the  desired outcomes have been achieved.

(While this Forum will focus on Leadership and Organizational decision-making, it will be followed in the next Forum with Evidence-based decision-making, especially encompassing our clinical commitments to the clinical teams and importantly, the patients and their families.)

Different Approaches to Decision-Making

While there are many ways to understand decision-making, let us distill it down to four distinct approaches and then consider how and when best to utilize them.


Defining Features

1. Collaborative

Leader consults and gathers information and then makes the decision(s).

2. Consensus

Leader facilitates a group process where all participate and support the decision(s).

3. Delegated

Leader enables others to make the decision(s).

4. Directive

Leader decides.

Collaborative decision-making - When utilizing a collaborative approach, the leader brings together the team for the purpose of gathering information, insight and asking for feedback.  While the leader is consulting, the team members know their contributions are important. Team members are willing to disagree, respect differences and understand that their ideas may not always prevail, yet they are influencing the ultimate decision.  The leader assesses all dimensions of the issue, genuinely listens to all sides of the arguments, and then the leader makes the final decision with the best input received from others.

When using a collaborative decision-making approach, the leader often has to consider external factors and comparative data, in addition to the ideas presented from within the team. (By some, this approach is sometimes referred to as "evidence-based” decision-making.)

Consensus decision-making – This is a group decision-making process that seeks “consensus” by all participants and requires a high level of trust among members. Typically this method is utilized when the expertise is “in the room” – that is, with the team and its members. The decision substantially affects all participants, and the leader wants to gain commitment and “buy-in” from everyone.  

Consensus based decision-making process allows everyone to speak, and thus usually takes more time. While there may be one or two  team members  who are reluctant to accept the decision or who are on the “edge” of accepting the decision, the leader  makes every effort to seek consensus and openly asks the question of those reluctant whether each "Can you live with the decision?” or "Can you support the direction?"  In my personal experience where I have used consensus decision-making, I have most often reached agreement and gained consensus  successfully which in turn helped to develop a culture of shared ownership and commitment to results. 

Delegated decision-making – Delegated decision-making assumes the leader has confidence in the managers who report to them and believe their staff and team have decision-making capacity. For example, when managers reporting to a leader ask for direction on matters that are clearly within their role and accountability it is preferable for leaders to refrain from giving answers or subtly giving direction; rather it is best to support or facilitate the managers with making the decision.

Delegation is not a matter of telling someone else what to do as some leaders view it.  The leader needs to clarify roles and accountabilities, define the results in the context of the overall plan and ensure that resources are available to achieve the outcome.

Delegated decision-making and supporting the decisions made by others strengthens individuals and teams and demonstrates the leadership practice of “enabling others to act”. (See authors J. Kouzes and B. Posner)  Ultimately delegation builds capacity and promotes a culture of shared leadership. 

Directive decision-making - Directive decision-making method is most often necessary in emergent/urgent situations where the individual or organization needs to move quickly. For example, when there is a fire or a patient is in crisis, among others. Directive decision-making is also occasionally utilized when new laws or rulings by the courts have been handed down.

Some leaders default to directive decision-making even when unnecessary. Leaders need to be thoughtful not to usurp decisions where those reporting to them can give direction as effectively as the leader.  In essence directives need to be used in circumstances when external forces require it, when under extreme time pressure, when there may be a series of factors imposed externally to the organization and when the leader has special knowledge needed to make the decision. Thus clearly there are some decisions where the leader is the best person to make the decision at the time.


Each decision-making approach is beneficial for certain times or circumstances.  As I reflect on my own leadership experiences in a variety of health care organizations, I recognize the challenge and the opportunity associated with employing different decision-making approaches.  Effective leaders are  thoughtful about making decisions, communicating those decisions as appropriate to those affected and as well as  skillfully  facilitating others  decision making within their  role and accountability and within the context of the organizations vision, goals and values --- ultimately providing  safe and high quality care.

Leadership and Organizational Decision-making

Discussion Questions

1. To what extent do you agree that these four different approaches substantially describe how most decisions are made in an organization?  Explain your reasoning and if appropriate describe alternative decision-making approaches. 

2. What approach to decision-making do you tend to utilize most often?

3. What one approach do you tend to utilize least? What are some examples of when it would be beneficial to use a different approach?

4. As a team member, how have you been engaged by your leader in collaborative decision-making and what were some of the pros and cons of this approach?

5. What are some reasons leaders are reluctant to use delegated decision- making?

6. Does this Forum in any way, make you rethink your approach to making decisions? If so, in what way?

Phil Hassen would like to acknowledge Jane Parkinson’s contribution to this piece of work.  Jane is Senior Facilitator, University Western Ontario, London, Ontario, Canada.

Suggested References

Garvin, D., & Roberto, M. (2001). What you don't know about making decisions. Harvard Business Review, 79 (8). 108-116.
Gleeson, B. (2012). 4 Ways for leaders to make a decision. http://www.forbes.com/sites.
Kouzes, J. & Posner, B. (2007). The leadership challenge (4th ed.). San Francisco, CA: Jossey-Bass.
Mankins, M., & Steel, R. (2006). Stop making plans; start making decisions. Harvard Business Review, 84 (1), 76-84.




Show threads from all forums that are: