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Evidence-based management - healthcare manager viewpoints

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 International Journal of Health Care Quality Assurance
Evidence-based management - healthcare manager viewpoints
Ali Janati, Edris Hasanpoor, Sakineh Hajebrahimi, Homayoun Sadeghi-Bazargani,
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 Evidence-based management - healthcare manager viewpoints

Introduction
There has been an intensive effort to develope new organization and administration models in the
last 20 years (Acton, 1998; Axelsson, 1998; Baba and HakemZadeh, 2012; Barends and Briner,
2014; Briner et al., 2009; Briner and Walshe, 2014). One model is evidence-based management
(EBMgt) (Axelsson, 1998; Bullock et al., 2012; Guo, 2015; Jaana et al., 2013). Hospitals, are
among the main organizations in the community that provide medical care services (Ford-
Eickhoff et al., 2011). Shifting healthcare perspectives over the last two decades has complicated
hospital management (Ford-Eickhoff et al., 2011). Consequently, complex hospital management,
as a skill and specialty, has become an important and pivotal issue (Alexander et al., 2007; Ford-
Eickhoff et al., 2011). Therefore, managers are forced to use evidence-based healthcare
management (EBHCMgt) to be effective (Guo, 2015; Hewison, 2004; Liang et al., 2012; White
et al., 2005). Evidence-based healthcare management improves organizational and managerial
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decisions by bridging theory and practice gaps, which has a critical impact on hospital
performance (Alexander et al., 2007; Axelsson, 1998; Guo, 2015; Hewison, 2004; Liang and
Howard, 2011; Liang et al., 2012; Majdzadeh et al., 2012; White et al., 2005). Evidence-based
management is rooted in evidence-based medicine (EBM) - a new approach to management
practice that requires healthcare managers to change (Axelsson, 1998; Guo, 2015; Walshe and
Rundall, 2001). Like EBM, EBMgt is a tool to respond to questions about a decision’s
consequence (Pfeffer and Sutton, 2007; White et al., 2005).
We live in an evidence-based everything era and that everything: medicine; nursing;
healthcare management; decision making and hospitals, have become information-based (Acton,
1998; Liang et al., 2012). Hospital manager decisions have a significant impact on service
quality and hospital success (Guo, 2015). If healthcare managers don’t pay attention to
evidence-based decision making (EBDM), then they will face problems such as disorganization
and useless work. Yet, recent studies show that only 15 percent of physician decisions are
evidence based, so can physicians be hospital managers? (Rousseau et al., 2008; Walshe and
Rundall, 2001). High-quality hospital management is believed to have a positive impact on
mortality, staff well-being, employees efficiency, performance and productivity (Agarwal et al.,
2016). Iranian hospitals continue to change into dynamic environments, partially owing to recent
political and also regulatory evolution (Kiaei et al., 2015). Hospital management requires
professional skills and hospital management - a specialized discipline demanding training and
skills - cannot be exclusively acquired in the job. Most Iranian hospital administrators are
physicians (Rabbani et al., 2015). Several management and medical informatics schools in Iran
educate students and produce chief executive officers (CEOs). However, hospital managers are
rarely employed in managerial positions. Low expertise in management and weak direction are
the main reasons why many important hospital initiatives fail (Rabbani et al., 2015). One
primary step to promote EBDM is to identify the challenges facing EBMgt. Recognizing specific
EBMgt attitudes and perceived barriers can promote new workplace-behaviors. Our purpose,
therefore, was to determine Iranian hospital EBMgt’s components and challenges.

Theoretical/conceptual framework: EBMgt

Evidence-based management, an evolving discipline, originally borrowed from EBM, started in
the early 1990s (Barends et al., 2015; Guo, 2015). Evidence-based is a term created in the 1990s
1
 in medicine (Barends et al., 2014); nowadays its principles extend to various disciplines
including nursing, education, criminology, social work and public policy (Barends et al., 2015).
Inspired by the EBM movement, Axelsson (1998) introduced an innovative approach, calling it
evidence-based management, which he advocated to mean that healthcare managers should learn
to search for and critically appraise evidence from management research as a basis for their
practice. There are many standpoints regarding EBMgt that are inspired and presented by
management and organization specialists. Axelsson (1998), Walshe and Rundall (2001),
Rousseau et al., (2008), Pfeffer and Sutton (2007), Briner et al., (2009), Barends et al., (2015)
and Wright et al., (2016) investigated EBMgt, its applications and component. According to the
EBM pyramid, the literature presents different evidence levels that can be used by managers and
other healthcare professionals in their decision-making process. Evidence sources include: (i)
best available scientific research; (ii) organizational data; (iii) professional experience and
judgment; (iv) stakeholder values and concerns (Barends et al., 2015; Hewison, 2004; Jaana et
al., 2013; Liang and Howard, 2011; Liang et al., 2012). The EBMgt theoretical framework is
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shown in Figure 1, which includes two phases.

Figure 1 here

The first phase is the EBDM cycle, which is implemented in six consecutive stages. The second
phase is evidence sources to be considered when making decisions. Many factors play different
but significant roles that affect EBMgt, including: (i) facilitators; (ii) barriers; and (iii) predictors.
Based on the literature, therefore, we divide EBMgt into three phases (Guo, 2015; Hyder et al.,
2010; Liang et al., 2012; Majdzadeh et al., 2008):

First Phase (1998 - 2005): Introducing and offering: the EBMgt movement lasted from 1998 to
2005. Throughout, writers began to formulate EBM and apply its principles to healthcare
management practice.

Second Phase (2006 - 2012): Publishing and production: ran between 2006 and 2012. During
this time, more scholarly EBMgt articles and books were produced.

Third Phase (2013- future): Adoption and utilization: proceeded from 2013 and continues.
Healthcare EBMgt been discussed for more than 16 years. Therefore, it seems important to
consider the challenges and factors affecting EBMgt in healthcare organization, especially
complex organizations like hospitals. Identifying challenges, based on the healthcare managers’
viewpoints, can assist hospital managers and researchers.

Methods
Study design and sample
We used qualitative methods to achieve our aims. Semi-structured interviews with 45
participants were conducted in 2016. We also ran three focus group discussions (FGDs) with 27
health managers. Participants included policy-makers and MOHME managers, research
managers and policy-makers elsewhere, hospital managers, health policy, management and
health research, and experienced administrators. Participants’ characteristics are displayed in
Table I. Iranian Center of Excellence in Health Management (ICEHM) staff sent a formal letter

2
 explaining the study to 56 experts in seven provinces (Tehran, East Azerbaijan, West Azerbaijan,
Qazvin, Ardabil, Yazd and Hamadan). Forty-five agreed to be interviewed.

Data collection
The FGDs involved researchers and healthcare managers, and in-depth interviews included
policy-makers and managers. Before the interviews, top managers in each organization
identified, named and defined change initiatives, which were underway. Nine participants
participated in each FGD. Interviews continued until data saturation was achieved. Both
interviews and FGDs were conducted by one researcher and one note-taker. Interviews and
FGDs lasted 60 to 90 minutes. Our research questions (RQ) investigated manager viewpoints and
barriers to EBMgt:

RQ1: What evidence sources did managers consult in their decisions?

RQ2: What are the managers’ views about hospital EBMgt?
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RQ3: What contextual barriers do managers perceive when using EBMgt?

RQ4: What are the managers’ views about EBMgt components?

Table I here

Interviews included questions on Iranian hospital EBMgt challenges and components and its
implementation procedures. We used the Tehran University of Medical Sciences (TUMS)
knowledge translation model to design in-depth interviews and FGDs guidelines (Majdzadeh et
al., 2008). A semi-structured questionnaire was developed for both FGDs and in-depth
interviews, which included: EBMgt’s meaning, features, benefits, predictors, challenges and
outcomes and factors influencing EBMgt, organizational processes involved in implementation,
what has and has not worked well and what is needed for the future. Open questions were used to
encourage participants to elaborate their EBMgt experiences. We used a questionnaire to collect
demographic data. Other questions asked about evidence sources, current knowledge and
participants’ attitudes to EBMgt.

Analytical approach
Our qualitative analysis, based on previous knowledge about EBMgt, aimed to investigate
challenges to better understand hospital EBMgt. We applied deductive content analysis when
coding interview data, using the theoretical framework dimensions (discussed earlier). All
transcripts were read. Challenges and components were coded as themes. Homogeneous themes
were composed, and categories created. To achieve triangulation, a weekly research meeting was
held to discuss interview status and feedback, and to seek consensus about any interview coding
issues. During the coding process, researchers made an initial pass through the transcripts
followed by coding clarification and assignment criteria. Next, they reevaluated code
assignments and made corrections based on the definitions that resulted from discussion in
research meetings. All documented in-depth interviews and FGDs were reviewed independently
by two researchers to ensure reliability. When there was disagreement, the group made the final
decision.

Ethical considerations

3
 The project proposal was approved by the Tabriz University of Medical Sciences ethical
committee (project code: TBZMED.REC.1395.497). After the study’s objectives had been
explained, participants’ oral consent was obtained at each session.

Results
Forty-five interviews (27 men) were administered between June and November 2016). Mean age
was 39.4 (sd = 9.34) years. Participants’ average work experience was 11.1 (sd = 8.47) years
(Table II). Twenty-nine participants had PhDs.

Table II and III here

As Table III indicates, most respondents based their management decisions on: (i) literature
(91.12%); (ii) knowledge acquired through formal education (86.67%); (iii) scientific research
(75.55%); (iv) personal judgment (71.12%); and (v) advice from colleagues (60+%). Only a few
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participants said that they based their decisions on trial and error (13.34%). Results showed that
most participants were familiar with online databases. All were familiar with Google Scholar and
90% knew other databases including PubMed/Medline, Web of Science, SID and Magiran. Only,
17.18% used Cochrane. Our results show that most participants weren’t familiar with research
terms like: controlled study (22.23%); confidence intervals (20%); sensitivity (28.89%);
generalizability (28.89%); bias (15.55%); and systematic reviews (26.67%). Ninety-one percent
had conducted scientific research. Almost, all believed in ethical evidence. Only, 26.67 percent
read a research article every day. Table IV shows the main themes, sub-themes and final codes
for each EBMgt dimension: EBMgt evidence sources, predictors and barriers; and evidence-
based hospital management (EBHMgt) processes. According to the final codes we extracted,
evidence sources were divided into six categories: (i) scientific and research evidence (SRE); (ii)
hospital facts and information; (iii) political-social development plans; (iv) professional
expertise; (v) ethical-moral evidence (EME); and (vi) stakeholder values and expectations. These
evidence sources determined administrators' management domain. An evidence-based hospital
manager is someone who has full control over all evidence sources.

Table IV here

The main predictors we identified were: stakeholder values and expectations; functional
behavior; knowledge; key competencies and skill; evidence levels and use; benefits and
programs, which were closely related to other main themes. These predictors determined
EBMgt’s theoretical framework (Table IV). The EBMgt barriers were categorized into the
following areas: barriers related to managers’ characteristics; decision-making environment;
training and research system; and organizational barriers. To understand the barriers, we
described the categories in more detail (Table IV). Quotations and their interpretation confirmed
that evidence-based hospital management was like the EBDM process. Our results show that
EBHMgt contains six stages: (i) asking; (ii) acquiring; (iii) appraising; (iv) aggregating; (v)
applying and (vi) assessing. Results indicate that at the beginning, the practical issue or problem
must be translated into an answerable question. Then, evidence is searched systematically. In the
third phase, evidence should be appraised using appropriate tools. Afterward, hospital managers

4
 should aggregate the evidence and decide using the best evidence. At the end, decision outcomes
must be evaluated.

Discussion
We identified the EBMgt barriers evidence sources as EBMgt predictors and EBHMgt, looking
from researchers’ and managers’ perspectives. Hyder et al., (2010) identified the challenges and
strategies when using knowledge in developing countries. Inappropriate communication,
heterogeneous aims and researchers/decision-makers’ languages, policy-makers' limited
professional skill, resource restrictions, organizational culture and parliamentary and budgetary
policies were identified as the main barriers. According to Majdzadeh et al., (2012), Iranian
health system EBDM barriers are categorized into: decision-makers’ characteristics; decision-
making environment; and research system.
Barends et al., (2015) investigated managers’ attitudes in Belgium, Netherlands and the
United States. Most respondents (60%) reported that they had insufficient time to read research
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articles and they regarded time limitation to be the main barrier. Also, not understanding
scientific research (56%) and research ambiguity (42%) were the main barriers. Other barriers to
managers’ using scientific research were organizational culture. The main barriers we identified
were consistent with systematic reviews in medicine, nursing and other studies (Guo, 2015;
Kajermo et al., 2010; Patelarou et al., 2013; Solomons and Spross, 2011; van Dijk et al., 2010).
According to principles, evidence must be: scientific; organizational; experiential and
stakeholder (Barends et al., 2014). In our study, this classification was changed. Interviewees
suggested that evidence sources were categorized into six domains. Evidence-based managers
are like spiders; i.e., they dominate all six evidence sources. As shown in Figure 2, we identified
EBMgt evidence sources and management domains. Depending on the problem, using the
EBHMgt process, managers will select the best available evidence and sources. Participants
believed that political-social development plans and ethical-moral evidence can be useful
evidence sources in the decision-making process.

Figure 2 here

A fully evidence-based hospital manager is a person who uses evidence sources in a six-step
decision-making process. Hospital managers should use the best evidence based on the problem
and population. Those who use only one evidence source, cannot make decisions properly. As
shown in Figure 2, depending on the source, managers may decide on one or several areas in all
organizational decisions. Hospital EBMgt predictors can provide information on the gaps
between knowledge and practice to improve decision-making processes (Guo, 2015). The main
predictors in our investigation were: stakeholder values and expectations; functional behavior;
knowledge; key competencies and skill; evidence sources and levels; evidence use and benefits;
and government programs. Although our findings agree with Guo (2015), Barends et al., (2015)
didn’t find a significant relationship between education, experience and attitude towards EBMgt.
Liang et al., (2013) conducted a mixed-method study in Australian public hospitals and showed
that evidence-informed decision making required certain skills, knowledge and attitudes. A
positive attitude toward EBMgt, adequate and appropriate knowledge from hospital and
management and EBDM skill are EBMgt predictors. Almost, all participants (n = 44) believed
that healthcare management can be evidence-based and had positive attitude towards EBMgt.
5
 The evidence-based hospital management framework is a useful tool to better manage
all healthcare organizations. In this framework, predictors, barriers, evidence sources and process
EBHMgt are explained and identified. It is essential to understand the context and interaction
between these factors. In that context, factors such as predictors, barriers and training
organizations, and research institutes can improve decision-making. In the Liang et al., (2012)
study, framework determinants can improve the evidence in managerial decision making. We
suggest that evidence-based decision-making is important when making management decisions.
In 2013, the elected Moderation and Development Party (MDP) began to change the health
sector; i.e., the Health Sector Evolution Plan (HSEP) or Health Transformation Plan (HTP) were
designed by the Ministry of Health and Medical Education (MoHME) to achieve universal and
comprehensive health services coverage. However, policy makers should not fail to engage
evidence-based professions (Moradi-Lakeh and Vosoogh-Moghaddam, 2015). To create and
implement evidence-based evolutions; we need to teach evidence-based healthcare managers to
apply their professional and expertise (Goodman et al., 2014; Niedźwiedzka, 2003). To adopt
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and use EBMgt, hospital leaders need to promote a culture that helps managers to dedicate time
to consult scientific evidence. Staff in educational institutions need to focus on improving
evidence-based management skills that are needed to find, read, evaluate and apply scientific
evidence. University leaders need to train academics about methods needed to critically appraise
and summarize the best available evidence on a topic relevant to best practice.

Conclusion
Our study suggests that most participants have positive EBMgt attitudes and that most believe
that using evidence-based management can improve management decision making. Evidence-
based hospital management can improve management decisions and service delivery,
effectiveness and efficiency. Since EBMgt is an emerging approach, its practice among hospital
managers has been limited. Several factors exist at organizational and personal levels, which
play different and considerable roles. We know that many healthcare managers lack EBMgt
skills. Thus, they need to instigate evidence-based management through training organizations
and research institutes. Our framework helps hospital managers to pursue the multiple evidence
sources in knowledge utilization processes. Using six evidence sources, managers recognize the
best available evidence for management decisions and in an evidence-based decision-making
process to make the best decision. To increase EBMgt benefits and use in hospitals, training
organization and research institute staff must involve hospital managers to set research programs
and to guide and facilitate evidence interpretation.

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Acknowledgments: This article is based on an evaluation project supported by the Research

Affairs Deputy at Tabriz Medical Sciences University (TUOMS). The authors acknowledge the
Iranian Center of Excellence in Health Management team. Thanks are due to HassanZadeh, E.,
Gharayie, H., and MosaZadeh, Y for helping with data collection and all the interviewees for
giving their experiences.

Table I: Research participants

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Provinces (n= 8) Organizations (n= 16) Position Number

Expert in management sciences, associate
professor in health policy, economics and
East Azerbaijan ICEHM 9
management, managerial experience, senior
manager in ICEHM
Senior manager in Iranian EBM Centre of
Iranian EBM Centre of
East Azerbaijan Excellence, expert in systematic reviews and 4
Excellence
knowledge translation
Office director in the hospital management and
Tehran MoHME clinical service excellence, deputy of MoHME in 3
the field of planning, senior manager in MoHME
Hospital manager, faculty members in health
West Azerbaijan,
Health care organizations services management, associate professor in 6
Qazvin and Tabriz
health care management
Associate professor in health services
Tabriz University of
East Azerbaijan management and health information management, 4
Medical Sciences
managerial experience in hospital
Tehran University of Associate professor in health policy, economics
Tehran 4
Medical Sciences and management; managerial experience
Yazd University of Medical Associate professor in health services
Yazd 1
Sciences management
Associate professor in health services
Hamadan University of
Hamadan management, Managerial experience in health 3
Medical Sciences
sector
Uremia University of Managerial experience in health sector and
West Azerbaijan 1
Medical Sciences associate professor in health services management
Managerial experience in hospital,
Iran University of Medical
Tehran Senior manager in faculty of health management, 5
Sciences
faculty members in health services management
Ardabil University of Professor, management science, managerial
Ardabil 1
Medical Sciences experience
Associate professor of management science
East Azerbaijan University of Tabriz 1
(organizational policy making)
Professor of management science, managerial
Tehran University of Tehran 1
experience
Professor of management science, managerial
Tehran Tarbiat Modares University 1
experience
9
 Allameh Tabataba'i Professor of management science, managerial
Tehran 1
University (ATU) experience
Total 45

Table II: Interviewees

Demographics (n = 45)
Qualitative variables Frequency %
Male 27 60.00
Gender (percentage)
Female 18 40.00
Managers 10 46.70
current occupation group (percentage) faculty members 21 22.20
Both 14 31.10
Masters 2 4.40
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Ph.D. 29 64.40
Highest level of education (percentage) MD 7 15.60
MD, Ph.D. 5 11.11
MD, Specialists 2 4.40
Strategic planning 11 20.00
Change management 7 15.60
Process improvement 5 11.10
HRM 11 20.00
Main expertise and skill (percentage)
Quality management 2 4.40
Policy making 4 8.90
Financing 5 11.10
Accreditation 2 8.90
Quantitative variables Minimum Maximum Mean SD
Average age (years) 28 70 39.40 9.34
Average work experience (years) 1 39 11.11 8.47
Average health care management experience (years) 0 31 5.74 6.48

10
 Table III. Healthcare manager viewpoints

Items Frequency Agree %

Trial-error 6 13.34
Intuition-insight 10 22.23
Personal judgment 32 71.12
Acquired knowledge 39 86.67
Decision making Consult with internal colleagues 30 66.67
Consult with external colleagues 28 62.22
Management literature 41 91.12
Internet 22 48.89
Scientific research 34 75.55
Business Source Premier from EBSCO 9 20.00
Science Direct from Elsevier 18 40.00
PsycINFO 10 22.23
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Inter Science 9 20.00

ProQuest 29 64.45
Cochrane 8 17.18
CINAHL 9 20.00
Springer 28 62.23
Familiarity with online
Ovid 25 55.55
databases
PubMed/Medline 42 93.34
Scopus 32 71.12
Web of Science 41 91.12
Embase 9 20.00
Emerald 19 42.23
SID (Iranian) 42 93.34
Magiran (Iranian) 44 97.78
Google Scholar 45 100
Controlled study 10 22.23
Observational study 23 51.11
Case study 25 55.55
Confidence interval 9 20.00
Statistical significance 33 73.34
Internal validity 20 44.45
Familiarity with
Reliability 20 44.45
research terms
Sensitivity 13 28.89
Generalizability 13 28.89
Bias 7 15.55
Correlation 18 40.00
Systematic reviews 12 26.67
Sampling 18 40.00
Do you have experience conducting scientific research? 41 91.12
Was there special attention given to scientific research in your formal
29 64.45
education?
Do you believe ethical evidence? 44 97.78
Would you like healthcare management to be evidence-based? 44 97.78
Do you regularly search databases online? (once a week) 35 77.78
Do you regularly read research articles? (per day) 12 26.67
Are you familiar with health management journals? (more than twenty
20 44.45
journals)

11
 Table IV: Synthesis

Main themes Sub-themes Final codes

Academic journals
Scientific and Research Evidence Scientific evidence
(SRE) Research evidence
Observational evidence
Hospital information system
Management dashboard
Internal evidence
Facts and information of hospital
Data and facts
Supportive team of hospital
Evidence sources in
Questionnaires and checklists
EBMgt
Government laws
Political-social programs
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Political-social development plans

Programs of MOH
Experience
Managers’ professional expertise Skill
Profession
Religious evidence
Ethical-Moral Evidence (EME) Ethical evidence
Moral evidence
Values
Stakeholder values and expectations Expectations and concerns
Stakeholders
Attitude toward the EBMgt
Functional behavior
Intention to use EBMgt
Managerial
Knowledge Organizational
Health care
Key competencies and skill Key competencies and skill
Internal evidence
Evidence sources
External evidence
EBMgt Predictors Evidence levels Levels of evidence
Uses of evidence Uses of evidence
Efficiency
Benefits Effectiveness
Quality
Regulations
Government programs Policies
Plans
Absent criteria for selecting decision-
makers
Few reward and incentive mechanisms
Managers’ characteristics Insufficient knowledge and negative
EBMgt Barriers attitude toward EBMgt
Non-executive administration
Lacking administrative and financial skills
Organizational value
Decision-making environment
Restricted perspective

12
 Situation of policy environment
Lack of coordination
Lack of skill and competencies
Lack of communication with the scientific
Training and research system and research institutions
Lack of specialization in hospital
management
Lack of evidence-based educations
Excessive bureaucracy and inappropriate
structure
Organizational culture
Organizational barriers Limitation of financial and human
recourses
Lack of time
Lack of teamwork
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Questioning
Asking Translating
Problems
Searching
Acquiring Finding
Source of evidence
Evidence-based
hospital Validity and accuracy
management process Appraising judging
Appraising
Aggregating Arranging
Decision-making process
Applying
Implementation
Assessing Evaluation

13
 Figure 1: EBMgt theoretical framework (Center for Evidence-Based Management (CEBM))

Asking Acquiring Appraising Aggregating Applying Assessing

EBDM process

Professional Stakeholders’ Organizational

Available
experience and values and data, facts and
scientific research
judgment concerns figures
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Sources of evidence
Context

Facilitators, barriers and predictors affecting EBMgt in hospitals

14
 Figure 2. Evidence-based hospital management

1. Scientific & Research

Evidence (SRE)
5

6. Values and expectations 3 2. Facts & information of

of all stakeholders hospital
2

1
Ethics- Data and
oriented
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0 fact-based
managers managers

5. Ethical-Moral Evidence 3. Political-social

(EME) development plans

4. Managers professional
Sources of evidence and management zones expertise

Asking Acquiring Appraising Aggregating Applying Assessing

EBHMgt Process

Training
Predictors Barriers organizations
and research
institutes
Context

15

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