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OUTCOMES ANALYSIS, QUALITY IMPROVEMENT, AND PATIENT SAFETY
Decision Making, Evidence, and Practice
Kevin W. Lobdell, MD, Geoffrey A. Rose, MD, Aneil K. Mishra, PhD,
Juan A. Sanchez, MD, and James I. Fann, MD
Department of Cardiothoracic and Vascular Surgery and Department of Cardiology, Atrium Health, Charlotte, North Carolina; College
of Business, East Carolina University, Greenville, North Carolina; Department of Surgery, Johns Hopkins University School of
Medicine, Baltimore, Maryland; and Department of Cardiothoracic Surgery, Stanford University, Stanford, California
n April 19, 1995, a 45-year-old man, standing 50 700
Oand weighing 270 pounds, robbed 2 banks during
daylight hours with no mask. Surveillance camera footage
was shown on the local 11 P.M. news, and minutes later, a
tip was received. Approximately 1 hour later, McArthur
Wheeler was in police custody and passionately stated,
“but I wore the lemon juice. I wore the lemon juice.”
Apparently, Wheeler knew that lemon juice is often a key
ingredient for invisible ink and deduced that his face
would be invisible to surveillance cameras. In fact,
Wheeler told police that he tested his scheme by exper-
imenting with a Polaroid camera. Wheeler suffered from
flawed judgment, decision making, and a poorly designed
experiment [1].
Preventable medical errors are estimated to take as
many as 200,000 lives and cost approximately $20 billion
annually in the United States [2]. Errors in medical de-
cision making have been highlighted by the Institute of
Medicine [3, 4], and further, the Society to Improve
Diagnosis in Medicine posits that 1 in 10 diagnoses are
incorrect and that these errors may account for 40,000 to
80,000 deaths annually in the United States [5].
Unnecessary variation and untoward outcomes may be
reduced through routine use of evidence-based medicine
(EBM) and evidence-based practice (EBP). EBM has been
defined as “the conscientious, explicit, and judicious use
of current best evidence in making decisions about the
care of individual patients,” and the randomized,
controlled trial is the gold standard in evaluating therapy
in EBM [6]. EBP includes information regarding diag-
nosis, prognosis, therapeutics, management strategies,
and outcomes through quantified measurements and
analytics [7].
To understand threats to decision making, quality, and
patient safety, considering common cognitive phenom-
ena and foibles with the individual (patient or practi-
tioner), the team, and the institution is vital. Recognizing
how decisions are made, information flows, innovation
diffuses, and knowledge is managed is also vital. The
following will briefly review commonly accepted theory
and practice to assist the reader in understanding threats.
Strategies to improve decision making, performance, and
reliability, while closing the gap between evidence and
practice, will also be discussed.
Address correspondence to Dr Lobdell, PO Box 32861, Charlotte,
NC 28232; email: kevin.lobdell@carolinashealthcare.org.
� 2018 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
Threats to Decision Making
Threats to individual decision making are manifold.
Consider the following examples of flawed reasoning [8]:
1. 88% of drivers in the United States rate themselves as
above average.
2. Software engineers from company A and company B
were individually asked whether they were in the top
5% of software engineers: 32% of company A and 42%
of company B software engineers rated themselves as
being in the top 5%.
Both examples suggest illusory superiority. This phe-
nomenon, known as the “Dunning-Kruger effect,” high-
lights a poor performer’s lack of skill and the necessary
knowledge to identify his or her meager performance.
Interestingly, amateurs have been found to rate them-
selves comparable to experts in various endeavors that
include, but are not limited to, humor, grammar, and
logical reasoning. Even college debaters—where the
bottom 25% of performers lost 80% of their debates, but
estimated their rate of winning at 60%—demonstrate
illusory superiority [9, 10].
Inattentional blindness, where naïve observers may
overlook important information, is another phenomenon
that may threaten decision making. The classic “invisible
gorilla experiment” (http://www.theinvisiblegorilla.com/
videos.html) is a graphic example of how perception
can mislead us. Drew and colleagues [11] demonstrated
that experts are also prone to inattentional blindness, as
captured in their experiment with lung nodule detection
with computed tomography scans, where a gorilla, 48
times larger than the average lung nodule, was over-
looked by 83% of the 24 radiologists tested (Fig 1).
The dual process theory of psychology suggests that we
have fast-unconscious and slow-conscious modes of
thinking. On one hand, type 1—fast thinking—is learned
by experimenting, especially through trial and error, and
includes rules of thumb, best practices, intuitive judg-
ment, and common sense [12, 13]. Cognitive shortcuts,
also known as heuristics, and biases are associated with
this unconscious, quick thinking. Among common
cognitive biases are anchoring, ascertainment, availabil-
ity, confirmation, diagnostic momentum, framing effect,
and desire for premature closure [14, 15]. Teleologically,
human evolution and survival depended on quick
thinking and action (without logical, conscious decisions)
in threatening situations.
Ann Thorac Surg 2018;105:994–9 � 0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2018.01.054
http://www.theinvisiblegorilla.com/videos.html
http://www.theinvisiblegorilla.com/videos.html
mailto:kevin.lobdell@carolinashealthcare.org
http://crossmark.crossref.org/dialog/?doi=10.1016/j.athoracsur.2018.01.054&domain=pdf
https://doi.org/10.1016/j.athoracsur.2018.01.054
Fig 1. Gorilla opacity
increased from 50% to
100%, then back down to
50% over the course of 5
frames within the chest
computed tomography
scan. (Reproduced with
permission from Drew T,
V~o ML, Wolfe JM. The
invisible gorilla strikes
again: sustained inatten-
tional blindness in expert
observers. Psychol Sci
2013;24:1848–53.)
995Ann Thorac Surg QUALITY REPORT LOBDELL ET AL
2018;105:994–9 DECISION MAKING, EVIDENCE, AND PRACTICE
On the other hand, the archetype for the slow, type 2
process, is a probability computation, which requires
time and mental energy. Numbers and probabilities are
notoriously and adversely affected by use of heuristics.
Cognitive load and imperfect memory, along with
incorrect attribution of cause, are additional common
threats to decision making. Furthermore, it is note-
worthy that decision neuroscience suggests that judg-
ment begins with rapid, unconscious weighting of
emotional tags from memory [16] and that emotion is
known to substantively affect judgment and decision
making [17, 18].
There is significant promise for wisdom in groups,
provided the groups (or group members) address
potential problems of cognition, coordination, and coop-
eration as well as conditions of diversity and indepen-
dence, recognizing the real-world clinical threats of
eminence, vehemence, eloquence, providence, diffidence,
and confidence, among others [19, 20]. The heart team,
multidisciplinary care, and teaming are common exam-
ples of the use of groups to provide diversity in expertise
and decision making [21, 22]. Conversely, the manage-
ment classic, “The Abilene Paradox” suggests that group
dynamics may also challenge group decisions [23]. This
illustrative phenomenon, where a group agrees to do
something even though privately and individually most,
or all, members of the group disagree with the group’s
decision (a violation of the condition of independence).
As this implied, a group can end up in “Abilene,” where
nobody really wanted to go.
Institutions, with their structure, processes, and history
of favorable outcomes, may also fail, not just simply but
spectacularly, in their decision making. For example,
during the many years that Kodak dominated the film-
based photographic processmarket, Kodak also had
Steve Sasson on its payroll, who in 1975 created the digital
camera. Because it did not disrupt itself (or jeopardize its
market and, hence, revenue), Kodak did not embrace
digital photography in a timely fashion [24, 25]. As a
result, Kodak filed for bankruptcy in 2012. Jim Collins’
research suggests that there is a reproducible pattern of
institutional failure described in 5 stages [26]:
1. Hubris born of success
2. Undisciplined pursuit of more
3. Denial of risk and peril
4. Grasping for salvation
5. Capitulation to irrelevance or death
Stage 2 suggests that institutions commonly make
decisions based on marginal costs and marginal revenues
(the things that historically generated profit), which also
makes these same institutions fodder for disruptive
innovators [27]. Analogously, Nelson and Winter suggest
that, “much of firm behavior is best understood as a
reflection of general habits and strategic orientation from
the firm’s past rather that the result of detailed survey of
the remote twigs of the decision tree” [28]. These exam-
ples are emblematic of the contemporary bewilderment
witnessed in health care institutions during the trans-
formation from “volume to value.”
More generally, high-performance organizations
intentionally and intensely focus on achievement and are
marked by common aspirational goals, adaptability,
alignment, and accountability [29–32]. Axiomatically, any
deviation from these characteristics poses a threat to
performance. Steven Covey [33] relates the following
illustrative examples of threats to fundamental compo-
nents of high-performance organizations (based on a
Harris Poll of 23,000 United States employees):
� 37% of employees have a clear understanding of
what their organization is trying to achieve and why
� 20% were enthusiastic about their organization’s
goals
� 15% felt their organization fully enabled them to
execute on key goals
� 10% felt their organization held employees
accountable for results
Idea Flow
Adam Smith’s “Invisible Hand” [34] suggests that it is
inherent to human nature to exchange ideas, assistance,
and favors out of sympathy. Alex Pentland’s [35] ongoing
research points to exposure, exploration, and engagement
as fundamental to this idea flow. Importantly, Pentland
finds that the rate of idea flow predicts half of the varia-
tion in the productivity of organizations. Many diverse
ideas and “dense interaction” are also characteristic of
high-performance groups. Furthermore, decisions are
found to be a combination of personal and social
996 QUALITY REPORT LOBDELL ET AL Ann Thorac Surg
DECISION MAKING, EVIDENCE, AND PRACTICE 2018;105:994–9
information. For instance, when personal knowledge is
low, one places increased weight on social information.
This “testimonial” approach is thus often used by patients
seeking qualified medical and surgical care.
Diffusion of Innovation
In the classic Diffusion of Innovation, published in 1962,
Everett Rogers [36] categorized adopters as innovators,
early adopters, early majority, late majority, and laggards.
The process of dispersion and adoption of innovation are
overwhelmingly reliant on human capital, and the rate
varies with many factors. In medicine, research evidence
is commonly estimated to require 17 years to become
accepted practice [37]. Profound threats to quality, safety,
and timely returns on investment can result from medi-
cine’s reluctance to change and the sluggish pace of
adoption.
Knowledge Management
To assist providers in reviewing and interpreting avail-
able medical evidence in patient management, organi-
zations, such as The Society of Thoracic Surgeons (STS)
and the American Association for Thoracic Surgery, have
developed consensus guidelines based on comprehensive
review of clinical and scientific data [38, 39]. The STS
Workforce on Evidence Based Surgery is tasked with
defining and addressing controversial clinical topics by
providing guidance, thereby ensuring thoughtful patient
evaluation and mitigating cognitive biases. The STS and
American Association for Thoracic Surgery have also
collaborated with general and interventional cardiology
organizations to define diagnostic and management
guidelines for the multidisciplinary management of
ischemic heart disease, aortic and mitral valve disease,
cardiac arrhythmias, thoracic aortic disorders, and gen-
eral thoracic malignancies [38, 39]. Appropriate guideline
use requires monitoring and commitment to learning and
improvement, as evidenced by the observation that of
patients with indications for coronary artery bypass
grafting (CABG), 53% were recommended for CABG and
34% for percutaneous coronary intervention (PCI); in
contrast, of patients who had indication for PCI, 94% were
recommended for PCI [40]. Furthermore, of patients with
an indication for CABG or PCI, 93% had recommendation
for PCI and only 5% for CABG [40].
All guidelines will have strengths and limitations. Bias
may be introduced into these efforts through study
design (eg, criteria for inclusion and exclusion, statistical
methods and analysis, and timeline for follow-up) and
expert opinion. The rate at which information accrues and
analyzed is also increasing and creates challenges to the
painstaking process of guideline creation and knowledge
transfer.
In addition, a less rigorous but highly practical aid in
decision making is represented by the STS Expert
Consensus Documents, which reflect the collective opin-
ions of experts in the field [41]. The opinions expressed
using this approach do not necessarily reflect a formal
evidence review based on the process outlined for
evidence-based guidelines. Nonetheless, the clinician is
provided with treatment strategies based on the collective
knowledge and experience of a committee of experts. For
instance, in the expert consensus for resuscitation of
patients who sustained cardiac arrest after cardiac sur-
gery, a task force was convened to review all relevant
medical literature, with the development of consensus
using a modified Delphi method with two rounds of
voting [42]. Importantly, the task force proposed a pro-
tocol that takes into account a number of variables, such
as defining six key roles that should be allocated
and rehearsed as a team, the procedural rationale
and sequence for pacing and defibrillation, and the
indications for repeat sternotomy (Fig 2) [42].
The conclusions and recommendations generated by
professional organizations may minimize the potential for
individual biases in patient care. Notwithstanding the
many topics addressed and consensus documents
developed by the STS and the American Association for
Thoracic Surgery, many clinical situations have yet to
have such robust guidance and thus require continued
awareness of potential biases and the many pitfalls in
clinical decision making.
Pragmatic Tactics
Inexperience with complex medical issues and emotional
overlay may affect a patient’s ability to make an informed
and thoughtful health care decision. The shared decision
making process, therefore, is designed to engage,
educate, and assist patients in understanding risks, ben-
efits, and alternatives to their therapeutic options and
appears to improve “value-congruent choices” [43].
The practitioner is encouraged to develop a framework
to categorize problems in the clinical environment. Based
on methods of complexity theory, the Cynefin [44–46]
framework, is a pragmatic paradigm that we use (inde-
pendent of the temporal dimension or time constraints
for decision making). Such a framework can mitigate the
potential risk of emotions on decision making by opera-
tional routine and elimination of variation, which in turn
degrades performance (Table 1).
In addition, clinicians should aspire to personal
mastery in thought and action. As a part of their study on
executive decision making, McKinsey and Company offer
an assessment that evaluates the pattern recognition,
action orientation, stability, social harmony, and self-
interest [47].
Clinicians canavoid cognitive missteps, such as the
“Dunning-Kruger Effect,” by creating an environment
that nurtures thoughtful decision making. For example, a
safe environment promotes questioning of judgment and
decisions, solicitation of feedback, and emphasizes
continuous learning and improvement. Other common,
cognitive biases that can affect clinical decision making,
patient safety, and outcomes include the availability
heuristic, confirmatory bias, and egocentric bias [48–51].
For example, the availability heuristic, or an individual’s
tendency to assign greater value to recent events and a
Fig 2. Six key roles in the cardiac arrest. (ICU ¼ intensive care unit.) (Reproduced from Dunning J, Levine A, Ley J, STS Task Force. The Society of
Thoracic Surgeons expert consensus for the resuscitation of patients who arrest after cardiac surgery. Ann Thorac Surg 2017;103:1005–20, with
permission from The Society of Thoracic Surgeons.)
997Ann Thorac Surg QUALITY REPORT LOBDELL ET AL
2018;105:994–9 DECISION MAKING, EVIDENCE, AND PRACTICE
higher probability that such events will occur, is evident
when a recent blood transfusion reaction results in the
provider’s perception of a higher likelihood of a reaction
in the next patient who requires a transfusion. Moreover,
when one makes a diagnosis in the setting of limited in-
formation, it is important that one does not succumb to
confirmatory bias by only acknowledging data supportive
of one’s assessment or management strategy. Finally,
Table 1. Clinical Complexity Framework
Variable Simple Complicated Complex Chaos
Process Pathway Algorithm Considerations Considerations
and teaming
People RN & RT NP or PA Physician Heart team
NP ¼ nurse practitioner; PA ¼ physician assistant; RN ¼ regis-
tered nurse; RT ¼ respiratory therapist.
998 QUALITY REPORT LOBDELL ET AL Ann Thorac Surg
DECISION MAKING, EVIDENCE, AND PRACTICE 2018;105:994–9
egocentric bias occurs when the clinician is overconfident
in his or her diagnosis in the setting of missing data
points, thereby resulting in inaccurate probability
assessment. Notably, use of Kahneman’s 12-point
checklist in important decisions is a useful example of
process to avoid biases in decision making (Table 2) [52].
Teams should routinely assess and quantify risk and
institutionalize risk mitigation strategies [53]. This
approach may affect the diagnostic process and promote
institutional learning, where data are converted to tacit
knowledge and operational routine. As Thaler and Sun-
stein relate in their review of Moneyball: The Art of
Winning an Unfair Game, “We suspect that countless areas
of enterprise, both private and governmental, would
benefit from their own Billy Beanes and Paul DePodestas,
challenging widespread intuitions, or what ‘everyone
knows,’ with statistical information about what works and
what does not, and with performance measures that more
accurately reflect the true contribution to organizational
success. Baseball is not the only realm for which The Book
is in need of revision” [54].
Pentland’s [35] research on idea flow suggests we must
experiment and focus on teammates with strong social
ties. Furthermore, because new ideas become habit
through the process of social learning, we need to evolve
our educational methods and focus on communication.
Clinical medicine and research demands reliable execu-
tion, which is fostered by inquisitiveness, sharing of
information, empowerment, teamwork, and learning
quickly [55]. Reliability may be augmented with tools
such as goal sheets, checklists, and hand-off tools [32].
From a practical perspective, Brent James [56] suggests
that clinical processes of high impact be identified and
EBP built around such an approach. James emphasizes
that the process “blend into clinical workflow so that it
doesn’t rely on human memory” [56]. The EBP must also
be integrated with a learning system that combines data,
computerized analysis, and an expert at the interface of
the system and clinical environment. Similarly, Joint
Commission recommendations [57] consist of enhancing
Table 2. Kahneman’s 12-Point Decision Checklista
1. Self-interest 7. Anchoring
2. Affect heuristic 8. Halo
3. Group think 9. Sunk cost
4. Saliency 10. Overconfidence
5. Confirmation 11. Disaster neglect
6. Availability 12. Loss aversion
a Adapted from [52].
knowledge and awareness of cognitive bias, professional
reasoning, critical thinking, and decision-making skills.
The Joint Commission also suggests enhancement of
work system conditions and workflow design that affect
cognition.
Summary
Quality and safety, and the deviation from EBM and EBP,
may be threatened by individuals, teams, and institutions.
Knowledge of principles related to decision making and
biases, idea flow, and knowledge management is vital. A
disciplined focus on structure, process, institutional
learning, and the development of a culture of continuous
improvement will mitigate risk of threats to performance
and reliability and thereby improve patient safety.
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https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_28_Oct_2016.pdfDecision Making, Evidence, and Practice
	Threats to Decision Making
	Idea Flow
	Diffusion of Innovation
	Knowledge Management
	Pragmatic Tactics
	Summary
	References