Investigate the effects that evidence-based medicine is having on current quality assurance practices in health care. What are the specific effects of recent evidence-based studies,

Evidence-based management – healthcare

manager viewpoints Ali Janati

Iranian Center of Excellence in Health Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran

Edris Hasanpoor Department of Healthcare Management,

Maragheh University of Medical Sciences, Maragheh, Iran Sakineh Hajebrahimi

Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran, and

Homayoun Sadeghi-Bazargani Road Traffic Injury Prevention Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract Purpose – Hospital manager decisions can have a significant impact on service effectiveness and hospital success, so using an evidence-based approach can improve hospital management. The purpose of this paper is to identify evidence-based management (EBMgt) components and challenges. Consequently, the authors provide an improving evidence-based decision-making framework. Design/methodology/approach – A total of 45 semi-structured interviews were conducted in 2016. The authors also established three focus group discussions with health service managers. Data analysis followed deductive qualitative analysis guidelines. Findings – Four basic themes emerged from the interviews, including EBMgt evidence sources (including sub-themes: scientific and research evidence, facts and information, political-social development plans, managers’ professional expertise and ethical-moral evidence); predictors (sub-themes: stakeholder values and expectations, functional behavior, knowledge, key competencies and skill, evidence sources, evidence levels, uses and benefits and government programs); EBMgt barriers (sub-themes: managers’ personal characteristics, decision-making environment, training and research system and organizational issues); and evidence-based hospital management processes (sub-themes: asking, acquiring, appraising, aggregating, applying and assessing). Originality/value – Findings suggest that most participants have positive EBMgt attitudes. A full evidence-based hospital manager is a person who uses all evidence sources in a six-step decision-making process. EBMgt frameworks are a good tool to manage healthcare organizations. The authors found factors affecting hospital EBMgt and identified six evidence sources that healthcare managers can use in evidence- based decision-making processes. Keywords Hospital, Hospital managers, Evidence-based practice, Evidence-based management, Evidence-based decision making Paper type Research paper

International Journal of Health Care Quality Assurance Vol. 31 No. 5, 2018 pp. 436-448 © Emerald Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-08-2017-0143

Received 8 May 2017 Revised 5 September 2017 Accepted 17 September 2017

The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm

This paper 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. The authors thank E. HassanZadeh, H. Gharayie and Y. MosaZadeh for helping with data collection and all the interviewees for giving their experiences.

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Introduction There has been an intensive effort to develop 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). EBHCMgt improves organizational and managerial 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). EBMgt 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 do not 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 andmedical informatics schools in Iran educate students and produce chief executive officers. 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 EBMgt, 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 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 EBMgt, 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

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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: best available scientific research; organizational data; professional experience and judgment; and 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 shown in Figure 1, which includes two phases.

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: facilitators; barriers; and 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: it ran between 2006 and 2012. During this time, more scholarly EBMgt articles and books were produced.

Third phase (2013-future): adoption and utilization: it 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 Ministry of Health and Medical Education (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

EBDM process

Sources of evidence Context

Facilitators, barriers and predictors affecting EBMgt in hospitals

Asking Acquiring Appraising Aggregating Applying Assessing

Organizational data, facts and

figures

Available scientific research

Professional experience and

judgment

Stakeholders’ values and concerns

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

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Excellence in Health Management staff sent a formal letter explaining the study to 56 experts in seven provinces (Tehran, East Azerbaijan, West Azerbaijan, Qazvin, Ardabil, Yazd and Hamadan). A total of 45 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 60-90 minutes. Our research questions 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?

Provinces (n¼ 8) Organizations (n¼ 16) Position Number

East Azerbaijan ICEHM Expert in management sciences, associate professor in health policy, economics and management, managerial experience, senior manager in ICEHM

9

East Azerbaijan Iranian EBM Centre of Excellence

Senior manager in Iranian EBM Centre of Excellence, expert in systematic reviews and knowledge translation

4

Tehran MoHME Office director in the hospital management and clinical service excellence, deputy of MoHME in the field of planning, senior manager in MoHME

3

West Azerbaijan, Qazvin and Tabriz

Healthcare organizations

Hospital manager, faculty members in health services management, associate professor in healthcare management

6

East Azerbaijan Tabriz University of Medical Sciences

Associate professor in health services management and health information management, managerial experience in hospital

4

Tehran Tehran University of Medical Sciences

Associate professor in health policy, economics and management; managerial experience

4

Yazd Yazd University of Medical Sciences

Associate professor in health services management 1

Hamadan Hamadan University of Medical Sciences

Associate professor in health services management, managerial experience in health sector

3

West Azerbaijan Uremia University of Medical Sciences

Managerial experience in health sector and associate professor in health services management

1

Tehran Iran University of Medical Sciences

Managerial experience in hospital, senior manager in faculty of health management, faculty members in health services management

5

Ardabil Ardabil University of Medical Sciences

Professor, management science, managerial experience 1

East Azerbaijan University of Tabriz Associate professor of management science (organizational policy making)

1

Tehran University of Tehran Professor of management science, managerial experience

1

Tehran Tarbiat Modares University

Professor of management science, managerial experience

1

Tehran Allameh Tabataba’i University (ATU)

Professor of management science, managerial experience

1

Total 45 Table I.

Research participants

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RQ3. What contextual barriers do managers perceive when using EBMgt?

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

Interviews included questions on Iranian hospital EBMgt challenges and components and its implementation procedures. We used the Tehran University of Medical Sciences 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 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 A total of 45 interviews (27 men) were administered between June and November 2016). Mean age was 39.4 (SD¼ 9.34) years. Participants’ average work experience was 11.1 (SD¼ 8.47) years (Table II). Of them, 29 participants had PhDs.

As Table III indicates, most respondents based their management decisions on: literature (91.12 percent); knowledge acquired through formal education (86.67 percent); scientific research (75.55 percent); personal judgment (71.12 percent); and advice from colleagues (60+ percent). Only a few participants said that they based their decisions on trial and error (13.34 percent). Results showed that most participants were familiar with online databases. All were familiar with Google Scholar and 90 percent knew other databases including PubMed/Medline, Web of Science, SID and Magiran. Only 17.18 percent used Cochrane. Our results show that most participants were not familiar with research terms like: controlled study (22.23 percent); confidence intervals (20 percent); sensitivity (28.89 percent); generalizability (28.89 percent); bias (15.55 percent); and systematic reviews (26.67 percent). A total of 91 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

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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: scientific and research evidence; hospital facts and information; political-social development plans; professional expertise; ethical-moral evidence (EME); and 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.

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 EBHMgt was like the EBDM process. Our results show that EBHMgt contains six stages: asking; acquiring; appraising; aggregating; applying; and 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 should aggregate the evidence and decide using the best evidence. At the end, decision outcomes must be evaluated.

Demographics (n¼ 45) Frequency %

Qualitative variables Gender (percentage) Male 27 60.00 Female 18 40.00

Current occupation group (percentage) Managers 10 46.70 Faculty members 21 22.20 Both 14 31.10

Highest level of education (percentage) Masters 2 4.40 PhD 29 64.40 MD 7 15.60 MD, PhD 5 11.11 MD, Specialists 2 4.40

Main expertise and skill (percentage) Strategic planning 11 20.00 Change management 7 15.60 Process improvement 5 11.10 HRM 11 20.00 Quality management 2 4.40 Policy making 4 8.90 Financing 5 11.10 Accreditation 2 8.90

Minimum Maximum Mean SD

Quantitative variables Average age (years) 28 70 39.40 9.34 Average work experience (years) 1 39 11.11 8.47 Average healthcare management experience (years) 0 31 5.74 6.48

Table II. Interviewees

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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

Items Frequency Agree %

Decision making Trial-error 6 13.34 Intuition-insight 10 22.23 Personal judgment 32 71.12 Acquired knowledge 39 86.67 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

Familiarity with online databases Business Source Premier from EBSCO 9 20.00 Science Direct from Elsevier 18 40.00 PsycINFO 10 22.23 Inter Science 9 20.00 ProQuest 29 64.45 Cochrane 8 17.18 CINAHL 9 20.00 Springer 28 62.23 Ovid 25 55.55 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

Familiarity with research terms 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 Reliability 20 44.45 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 education? 29 64.45 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 20 journals) 20 44.45

Table III. Healthcare manager viewpoints

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Main themes Sub-themes Final codes

Evidence sources in EBMgt Scientific and Research Evidence (SRE)

Academic journals Scientific evidence Research evidence Observational evidence

Facts and information of hospital

Hospital information system Management dashboard Internal evidence Data and facts Supportive team of hospital Questionnaires and checklists

Political-social development plans

Government laws Political-social programs Programs of MOH

Managers’ professional expertise

Experience Skill Profession

Ethical-moral evidence (EME)

Religious evidence Ethical evidence Moral evidence

Stakeholder values and expectations

Values Expectations and concerns Stakeholders

EBMgt predictors Functional behavior Attitude toward the EBMgt Intention to use EBMgt

Knowledge Managerial Organizational Healthcare

Key competencies and skill Key competencies and skill Evidence sources Internal evidence

External evidence Evidence levels Levels of evidence Uses of evidence Uses of evidence Benefits Efficiency

Effectiveness Quality

Government programs Regulations Policies Plans

EBMgt barriers Managers’ characteristics Absent criteria for selecting decision makers Few reward and incentive mechanisms Insufficient knowledge and negative attitude toward EBMgt Non-executive administration Lacking administrative and financial skills

Decision-making environment

Organizational value Restricted perspective Situation of policy environment Lack of coordination

Training and research system

Lack of skill and competencies Lack of communication with the scientific and research institutions Lack of specialization in hospital management Lack of evidence-based educations

(continued ) Table IV. Synthesis

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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, the Netherlands and the USA. Most respondents (60 percent) reported that they had insufficient time to read research articles and they regarded time limitation to be the main barrier. Also, not understanding scientific research (56 percent) and research ambiguity (42 percent) 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 EME can be useful evidence sources in the decision-making process.

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

Main themes Sub-themes Final codes

Organizational barriers Excessive bureaucracy and inappropriate structure Organizational culture Limitation of financial and human recourses Lack of time Lack of teamwork

Evidence-based hospital management process

Asking Questioning Translating Problems

Acquiring Searching Finding Source of evidence

Appraising Validity and accuracy Judging Appraising

Aggregating Arranging Applying Decision-making process

Implementation Assessing EvaluationTable IV.

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findings agree with Guo (2015), Barends et al. (2015) did not find a significant relationship between education, experience and attitude toward 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 (n¼ 44) believed that healthcare management can be evidence based and had positive attitude toward EBMgt.

The EBHMgt 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 began to change the health sector, i.e. the Health Sector Evolution Plan and Health Transformation Plan were designed by the 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

EBHMgt Process

Context

5

1. Scientific and Research Evidence (SRE)

2. Facts and information of hospital

3. Political-social development plans

4. Managers professional expertise

5. Ethical-Moral

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