In a democratic emergency medicine group, there are many ways to arrive at decisions, from command-and-control to consensus-building. What works best will depend on the character of your group, and what you hope to achieve.
Critics of Robert’s Rules say that the process encourages adversarial debate and the formation of competing points of view and that these things in turn may harm group member relationships and/or undermine the ability of the group to cooperatively implement a contentious decision.
But consensus-seeking discussions can be just as adversarial and competitive as those under Robert’s Rules and successful implementation depends much more on group leadership and discipline enforcement than on group member goodwill.
In a democratic emergency medicine group, there are many ways to arrive at decisions, from command-and-control to consensus-building. What works best will depend on the character of your group, and what you hope to achieve.
“Time is the scarcest resource and unless it is managed, nothing else can be managed.”
-Peter Drucker
Organizational decision making in equal-ownership emergency medicine groups tends to be accomplished almost exclusively through consensus formation. Working to find a consensus is said to yield better decisions because it is more broad-based and it builds unity as the discussion unfolds. It’s also claimed that it eases decision implementation since everyone has had the opportunity to fully express their concerns in the course of the decision making process. Consensus-based decision making seeks unanimous consent to a decision though not necessarily unanimous agreement. Some group members may consent to a decision because its substance doesn’t affect them one way or the other, or because they are ambivalent about it, or because they don’t want to be viewed as an extreme outlier.
Consensus-based decision making is thought to be essential in groups of highly egocentric professionals where every group member, trained to be an independent thinker, is by definition equal to every other. Therefore, each person’s opinion is equally valid and each person holds veto power over every decision. Thus, a vote of 9 to 1 in an independent EM group really is just a tie.
The consensus-seeking process is characterized by initial divergence – each person is expected to have a unique opinion and there is some subtle pressure to show one’s insightfulness, intelligence, and grasp of the situation through the content of one’s opinion. At least among physicians, this is most often the origin of the discussion heading off track and ending up far afield of the original question. At the point of maximum divergence someone will usually suggest getting back on topic, which hopefully then leads to a convergence of opinions that leads in turn to compromise and resolution.
Consensus-based decision making is not without its problems, however. It is costly in terms of the value of the professional time consumed and the process is inefficient as anyone who has ever attended one of these meetings can attest. Decisions can be short-sighted when some of those deciding the question lack a full understanding of the issues and needs of the organization and its customers. The underlying pressure to achieve consensus on every decision can also lead to decisions that no one in the group supports (termed the Abilene Paradox after a paper of the same name) wherein multiple group members agree to a compromise decision because they thought that’s what someone else wanted or they didn’t want to “rock the boat.” Also, consensus building can make follow-up difficult because it lends itself to a diffusion of accountability. Finally, consensus-based decision-making in an equal ownership EM group can result in frequent “reconsiderations” of prior issues. Where everyone is equal it is always hard for some individuals to accept ‘no’ for an answer. The result can lead to second-guessing and endless debate over controversial issues, which in turn saps the energy of a small organization and prevents it from dealing with critical practice leadership and management needs.
Consensus-based decision making is but one of several ways decisions are made in most group enterprises, the others being Command, Delegation, and Democratic. Hill, McShane, and McShane, in their book The Principles of Management, point out that the antithesis of consensus-based decisionmaking is well illustrated by Robert’s Rules of Order. Robert’s Rules impose decision-making process restrictions, the goal of which is to enable a large group of people to reach a simple majority (Democratic) decision as efficiently as possible. Motions to reconsider require a majority vote to come to the floor, thus prohibiting the possibility of a single person taking control of the meeting’s agenda or vetoing a decision supported by all the rest. Critics of Robert’s Rules say that the process encourages adversarial debate and the formation of competing points of view and that these things in turn may harm group member relationships and/or undermine the ability of the group to cooperatively implement a contentious decision. But consensus-seeking discussions can be just as adversarial and competitive as those under Robert’s Rules and successful implementation depends much more on group leadership and discipline enforcement than on group member goodwill.
The best way to streamline EM group decisionmaking is to limit the number of questions that come to the group as a whole for a decision. Whether to accept a new partner or take on another hospital ED contract are examples of issues that should come before the whole group for discussion and decision. The department Christmas party, however, should not. The former issues must be decided by consensus but the latter can be quickly addressed either by the medical director or president (command decision) or referral to the Christmas Party Committee (Delegation). If you do employ multiple decision-making structures, be careful about overlapping authorities.
Questions of who is authorized to decide what kinds of issues are typically addressed in the group’s shareholder or operating agreement; they are referred to collectively as tiered authority and accountability. Generally, this section begins with the lowest level of authority and proceeds to the highest, that being the ownership as a whole. Some operating agreements focus on a dollar limit of authority while others specifically define what the person in that role can and cannot do. For example, the medical director is typically empowered to suspend someone from the schedule but not to terminate them, the latter requiring the consent of the Board of Directors or in small groups the ownership as a whole. The group president might have the power to obligate the group to spend $5,000 on the Christmas party but would have to seek Board approval for anything over that amount. All of these authorities and accountabilities should be defined in writing early in a group’s history. Any authority not specifically granted or in doubt should be considered to belong to the purview of the ownership as a whole.
Whatever process is used, once a decision is made, everyone in the group must support that decision regardless of their reservations about it. The nursing staff and administration cannot – and should not – be expected to alter their behavior based on which physician is on duty; you can’t build work flow processes that vary with the provider either. The EM group must speak with a single voice. Th
e same is true for enforcing accountability. When someone endorses a decision, the implementation of that decision should proceed as a matter of course and not be left to drift. Don’t leave the meeting without it being clear who is responsible for managing the implementation, when the project must be complete, and that everyone must be united about it front of the nurses and other staff.
The medical director should be granted the specific authority and accountability for enforcing discipline among all the group members, including his or her partners. This authority should include the authority to levy a consequence for repeat offenders, including referring the issue to the Board of Directors for their intervention. An EM practice should not be an experiment in interpersonal relationship skills rehabilitation but rather recognized for the multi-million dollar business it is. All it takes to make it work is good decisions and consistent follow through.
References
1. Harvey JB. The Abilene Paradox: The Management of Agreement. Organizational Dynamics, 3 (1) 63. 1974.
2. Hill CWL, McShane LS, McShane S. Principles of Management, 1st Edition, McGraw-Hill/Irwin,2010.
Ronald A. Hellstern, MD, FACEP is the Principal for Medical Practice Productivity Consultants