Adaptive decision-making: how Australian healthcare managers decide

Abstract

Despite many calls for the utilisation of research evidence in health policy-making, it is not widely practised, and little is known about how decision-makers in healthcare organisations actually make decisions. We recruited a purposive sample of Australian healthcare decision-makers to complete a web-based survey. We then took a sub-sample from willing respondents for individual interviews. All interviews were audio-recorded, transcribed verbatim and coded thematically. We found that resource allocation decision-making varied greatly across the Australian healthcare system. Decision-making was highly dependent on the operational context in time, place and purpose, and that research evidence was rarely exploited to its full potential. Decision-making involved a multifaceted interplay of elements in situation of inquiry. All decisions were made by networks or collectives of people; and no instance of individual decision-making was reported. This varied, social and contextual nature of decision-making points to a complexity that is not reflected in systematic evidence-based reviews or evidence-based models for decision-making, and we did not discover an appropriate model to reflect this complexity in the health- related literature. We developed a model of ‘adaptive decision-making’ that has potential to guide robust decision-making in complex situations, and could have some value as an explanatory or theoretical model for teaching and practice. What is known about the topic? The topic is certainly novel and original, relevant and timely for academics and healthcare decision-makers. Despite increasing calls for the use of systematic evidence-based reviews including economic evaluations, the way in which decision-makers arrive at their allocation decisions and how such decisions reflect concern for economic efficiency is often blurred. This topic is an important one for its relevance to the current difficulties in the complex situation of healthcare. What does this paper add? This paper shows that decision-makers acknowledged the integration of economic principles as contextual realities into their decision-making activities, rather than utilising the results of ever-more seemingly ‘technically sound’ economic evaluations, which cannot address the inherent uncertainty attached to complex decision-making activities. We developed a novel adaptive model of decision-making generated by the interplay of multiple behaviours and factors in the situation of inquiry. The model is new and takes into account the complexity of the context in time, place, purpose and administrative location. What are the implications for practitioners? This paper should be of interest to a broad readership including those interested in health economics, public health policy, healthcare delivery, healthcare resource allocation and decision-making. The adaptive decision-making model designed in this study has the potential as a guide or heuristic device for teaching and practice. Healthcare decision-makers need to be prepared for complexity and ambiguity and cannot expect the data to tell them everything they need to know. We expect to see a shift in the literature on healthcare decision-making, not away from evidence-based practice and economic evaluation, but towards contextualising these methods in broader, adaptive models of decision-making.