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REVIEW
Barriers, Facilitators, Process and Sources of Evidence for Evidence-
Based Management among Health Care Managers: A Qualitative
Systematic Review
Edris Hasanpoor1,2, Sakineh Hajebrahimi3, Ali Janati2, Zahra Abedini4, Elaheh
Haghgoshayie5*
ABSTRACT
DOI: http://dx.doi.org/10.4314/ejhs.v28i5.18
666 Ethiop J Health Sci. Vol. 28, No. 5 September 2018
There has been an intense effort toward evidence, experiential evidence and stakeholders’
developing modern models for organization and and patient’s expectations (1-3). The use of
administration, especially in the last 20 years. One evidence sources in decision-making processes
of these models is evidence-based management among healthcare administrators has the potential
(EBMgt) for managing different organizations. for a more productive, cost-effective, high quality
Originally, the concept of EBMgt was derived and efficient healthcare organizations (1, 2, 15,
from evidence-based medicine (EBM). Analogous 16).
to EBM, evidence in EBMgt serves as a tool to EBMgt has been slowly adopted by
solve problems about the likely result of a decision healthcare managers in the USA, the UK and
(1-6). Canada (16-18). However, a remarkable gap exists
EBMgt is an evolution in the practice of between this ideal scenario and the status quo (19,
management and organizations. There have been 20). The major factors were identified from the
debates regarding the adoption of EBMgt with different studies. EBMgt or EBDM have been
criticism since 1998, when EBMgt was in its early affected by several factors, including the
stages. While the theory of EBMgt is fairly organizational factors, facilitators, barriers,
youthful, it has become increasingly popular over strategies plus individual and social factors (11,
the past few years (1-3). 21, 22). Guo (2015) identified the strongest
EBMgt is imports making decisions through predictors of EBMgt among 154 healthcare
the accurate, clear and judicious utilization of the managers in the USA. The results showed that it
best available evidence from multiple sources to was important to create a culture and receive
increase the likelihood of a suitable outcome (1, 2, organizational reinforcement in the practice of
7). Therefore, managers have a responsibility to EBMgt (16). Alavi et al. conducted a study about
make effective and efficient decisions which help managers’ awareness of EBDM. The results
the mission and vision of their organization, showed that managers’ awareness of EBDM in the
similar to physicians, who utilize the best hospitals was 3.08 ± 1.13 (score range = 0-6) (15).
available scientific evidence in clinical decisions There are many theories regarding EBMgt.
about patients (8-10). These theories have been inspired by researchers
Researchers and managers have emphasized and experts of management and organization.
the demand for enhanced consideration and Axelsson, Konver, Walshe and Rundall, Pfeffer
mobilization of evidence-based decision making and Sutton, Rousseau, Briner, Barends, Edris and
(EBDM) to support management actions in Wright have all reviewed the concept, application
organizations. In point of fact, we live in a period and components of EBMgt in their studies in
of “evidence-based” everything, and that recent years (10, 23-29).
everything-medicine, management, disaster The purpose of this review was to identify
management, nursing, organizations and hospitals- factors and components of the EBMgt based on a
have become information-based. What matters is systematic review. Therefore, we wish to provide
managers makes the managerial decisions a practical framework for EBMgt, based on recent
according to the best available evidence. Hence, evidence. This framework is appropriate for
using evidence to aid management development managing health sectors, hospitals, industries and
and practice in organizations has earned high every organization. Therefore, we wish to provide
excellence (1-4, 11-14). a practical framework for EBMgt, based on recent
EBMgt means making decisions about evidence. Identifying factors affecting EBMgt and
managing organizations through the conscientious, designing the final framework of EBMgt is a new
explicit and judicious use of four multiplex perspective for managing organizations and can be
sources. The four sources of evidence for a new skill, practices and behavior.
management decision-making include the best
METHODS
available scientific evidence, organizational
DOI: http://dx.doi.org/10.4314/ejhs.v28i5.18
Barriers, Facilitators, Process and Sources of Evidence… Edris H. et al. 667
Search strategy and selection criteria synthesis were performed and reported
The search was formulated using the following according to the standards set out in Preferred
broad parameters: Reporting Items for Systematic Reviews and
Types of participants: In this review, studies Meta-Analyses (PRISMA) (30). The following
were included that healthcare managers (men and electronic databases were searched: PubMed,
women) worked at healthcare institutions or Web of Science, Cochrane, ProQuest, Embase
organizations who had used experiences of and Scopus. In addition, we searched Google
evidence-based management. The entire Scholar, Emerald, Academy of Management
healthcare managers at all levels of management (AOM) and the website for the Center for
(operational, middle and senior) in healthcare Evidence-Based Management (CEBMa) for
organizations were included. articles related to EBMgt. On the other hand,
references of relevant articles were checked that
Phenomena of interest: The studies were were not found in searching databases.
included that focus on the experiences and We used data sources up to September
perceptions of healthcare managers who had 2017, without language restriction. In addition,
experienced evidence-based management we updated searches through Google Scholar
approach. Studies focusing on healthcare and alert system of databases up to December
managers’ experiences and perceptions of non- 2017. The search strategies for the databases
evidence-based management were excluded. combined subject terms: Evidence based
Type of context: The context of the review was management [Title/Abstract], Evidence informed
healthcare institutions or organizations (any type management [Title/Abstract], Evidence based
of institution/organization) including all levels of decision making [Title/Abstract], Evidence
management from any setting globally. informed decision making [Title/Abstract],
Evidence based policy making [Title/Abstract],
Types of studies: The inclusion criteria were as
Evidence informed policy making
follows:
[Title/Abstract], Evidence based administration
• Primary studies (English) were included
[Title/Abstract], Evidence informed
• Qualitative studies, including (but not
administration [Title/Abstract], Evidence based
limited to), phenomenological, grounded health [Title/Abstract], Evidence informed
theory, ethnographic, case studies and health [Title/Abstract], Evidence based
thematic analysis studies of healthcare organization [Title/Abstract], Evidence informed
managers’ experiences and perceptions of organization [Title/Abstract], Evidence based
evidence-based management were hospital [Title/Abstract], Evidence informed
included. hospital [Title/Abstract], Organization
Studies that were not related to manager, [Title/Abstract], Administration[Title/Abstract],
administrator, director and other managerial Hospitals[MeSH Terms] and Evidence based
posts were excluded. Also, quantitative studies practice [MeSH Terms].
were excluded. The systematic review and meta-
DOI: http://dx.doi.org/10.4314/ejhs.v28i5.18
668 Ethiop J Health Sci. Vol. 28, No. 5 September 2018
DOI: http://dx.doi.org/10.4314/ejhs.v28i5.18
Barriers, Facilitators, Process and Sources of Evidence… Edris H. et al. 669
studied authors’ interpretations of the participants’ Of 174 articles excluded, 106 were review and
accounts. Data extraction forms were used by opinion articles.
thematic coding according to key articles and The quality levels of studies were designated
continued through all 23 articles. Also, the as strong, moderate and weak. The results of
synthesis was a cyclical process; when a new quality assessment showed that 20(53.84%)
theme was identified, we returned to the other articles were of high quality, and 9(34.62%) were
articles to survey the theme event. of moderate quality. The quality level of 3 studies
was low (11.54%).
RESULTS Included studies were 23, of which 20 were
qualitative studies and 6 were mixed-methods
Among the 26,011 records identified from
(Table 1). The main themes and outcomes
database searches, 17,278 remained after we
presented are evidence research in EBMgt,
removed duplicates, and 197 articles remained for
facilitating factors, EBMgt training, barriers and
full-text assessment. Overall, 26 studies were
facilitators to implementing supports for EBMgt,
selected (11, 15, 18, 19, 21, 22, 29, 36-65).
role of evidence in the decision-making of EBMgt,
However, 174 studies were excluded. Of the 26
components of EBMgt, EBMgt decision process,
studies assessed, the frequency of qualitative
and implications for designing EBMgt and factors
studies and mixed-methods were 20 and 6,
of evidence-based decision making (EBDM).
respectively; the quality of 3 studies was weak.
Meta-synthesis was conducted as per four main
Finally, 23 studies were included in the Meta-
outcomes and was categorized into the following
synthesis.
factors: facilitators (5 main themes), barriers (5
A total of 23 studies from 7 countries were
main themes), and sources of evidence (4 main
included: Canada (n=8), USA (n=6), Australia
themes) and the process of EBDM (one main
(n=4), UK (n=3), Iran (n=1) and Brazil (n=1);
theme). The results of synthesis are shown in
none were from Africa. The period of included
Table 2.
studies ranged from 2003 to 2016. Most studies
were conducted in the context of healthcare sector.
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Table 1. Continued…
Peirson et al., Canada To explore factors and Qualitative study Semi-structured Thematic Library personnel, directors, Public health unit Strong
2012 dynamics for building (case study) interviews (n=6) and analysis managers, supervisors and
evidence informed decision FGDs (n=21) specialist (n=70)
making capacity
Plath, 2013 Australia To illustrate the Qualitative study Semi-structured Content Senior executives, Senior National Moderate
implementation of evidence- (case study) interviews (n=24) and analysis staff, State and area organizations
based practice as an Focus Group managers, Team leaders and (n= 2)
organizational change process Discussions (n=5) Clinical specialists (n=24)
Plath, 2014 Australia To illustrate the model of Qualitative study Semi-structured Content Senior executives, Senior National Moderate
evidence based practice in (case study) interviews (n=24) and analysis staff, State and area organizations
organizations FGDs (n=5) managers, Team leaders and
Clinical specialists (n=24)
Richer et al., Canada To examine the notions of Qualitative study Individual semi- Content Decision makers and McGill Strong
2013 evidence in decision-making structured interviews analysis managers (n=11) University Health
processes in health care Centre
Scheller, 2014 USA To analyze the Qualitative study in-depth qualitative Content Leaders and managers of Long hospitals Strong
implementation of an (comparative case interviews analysis hospital and short health and short health
organizational change study) system (n=30) system
initiative (EBL)
Sosnowy et USA To determine use of decision Qualitative study Individual interviews Thematic Decision makers (Upper- Local health Moderate
al., 2013 making processes by (n=20), FGDs (n=2) analysis level staff) of Local health departments
leaders and identify and small-group departments (n=31)
facilitators and barriers to the interviews (n=5)
use of evidence based
decision making
Spiri and Brazil To understand the meaning of Qualitative study Individual semi- Content Senior nurse leaders (n=10) Public hospitals Strong
MacPhee, EBMgt to Brazilian senior (phenomenology) structured interviews analysis (n=10)
2013 nurse leaders
Wright, Australia To fill the gap in knowledge Qualitative study Semi-structured Inductive Emergency Hospitals Strong
Zammuto, et about the process and (case study) interviews (n=29) procedures physicians
al., 2016 particularities of EBMgt and registrars (n=24),
CEOs (n=4) and nurse
(n=1)
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Table 1. Continued…
Ferlie et al., UK To consider implications for Qualitative study Individual interviews Paired analysis General and clinical Health care Moderate
2012 designing a more modest (case study managers Phase 1: organizations(n=6)
project for EBMgt in health methods) (n=45) Phase 2:
care organizations (n=45)
Kohn, 2013 Canada To explores how evidence is Qualitative study Individual interviews Content analysis CEOs, Public hospitals (n=4), Strong
conceptualized by public ( A grounded healthcare leaders, academic health sciences
hospital theory approach) decision makers centers (n=2) and teaching
Executives (n=18) hospitals (n=2)
Jack et al., Canada To describe the Qualitative study In-depth semi- Content analysis Executive Canadian agencies (n=24) Strong
2011 types and sources of (descriptive) structured interview directors (n=8),
information used to inform Program managers
practice related (n=12), and service
decisions providers (n=6)
Armstrong Australia Describes how evidence is Mixed -method Semi-structured Descriptive CEOs (n= 135) Local government (n=45) Moderate
et al., 2014 used to inform local (cross-sectional telephone statistics and
government (LG) public survey and (n= 13) content analysis
health decisions interview)
Martelli, USA To support the construct of Mixed-method Questionnaire and Descriptive CEOs, CAOs, CFOs, Hospitals (n=42) Moderate
2012 knowledge variety of (cross-sectional semi-structured statistics CIO/CTO, CMO,
evidence-based management survey and interviews and content CNO, CHO (n=103)
for organizations. interview) analysis
Yost et al., Canada To evaluate the impact of an An explanatory Individual semi- Descriptive CEOs, University and health care Strong
2014 intensive education mixed- methods structured interview statistics and Associate medical organizations
workshop on Evidence (n=8), Questionnaire content analysis officer of health,
informed decision making program manager and
knowledge care provider (n=42)
Abbreviations:
CEOs: Chief Executive Officers, COOs: Chief Operating Officers, CAOs: Chief Administrative Officers, CFOs: Chief Financial Officers, CIO/CTOs: Chief Information/Technology
Officers, CMOs: Chief Medical Officers, CNOs: Chief Nursing Officers, HNs: Head Nurses, HDDs: Health Departments Directors
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Table 2. continued…
Training and Not having systematic health research prioritization, resource constraints, lack of communication between
research system knowledge producers and decision-makers, time to look for evidence, uncertainty of the evidence base
confidence in using research, lack of development of skills in finding, accessing and using, lack of research
and evaluation skills, lack of accessibility of management research, lack of transference of knowledge and
lack of EBMgt education. (11 factors)
Organizational bureaucracy and power dynamics within traditional organizational hierarchies, social and historical trends
barriers that impede innovation uptake and utilization, Organizational culture opposed to EBMgt, limited resources,
lack of time, workloads, lace of competing priorities, lack of leadership commitment, lace of regulations and
policies and lack of understanding by leadership. (10 factors)
Team barriers Resistance to change, resistance to the source of evidence, presence of inexperienced leaders and negative
attitude toward change. (4 factors)
Sources of evidence Organizational Organizational data, internal data, facts, extensive personal networks inside, social or political mandates,
( n= 9) evidence agency mandate and resources, agency service providers and agency clients. (8 factors)
Ellen et al., 2013; External evidence Scientific evidence from the professional literature, reports from other organizations to benchmark or
Francis-Smythe et al., compare with their own, Research evidence, tools, frameworks, and models to use with their data, extensive
2013; Jack et al., 2011; personal networks beyond, webinars, seminars and conference. (10 factors)
Kohn, 2013; Oliver, Evidence related Trial and error, personal values, leaders’ knowledge of the organization, its employees, and patient
2013; Richer et al., 2013; to managers population; formal education, previous experience, instinct and common sense. (7 factors)
Sosnowy et al., 2013; Types of evidence Research evidence, best practice guidelines, perceived best practices, local program evaluations, client needs
Spiri and MacPhee, assessments, expert opinion, personal professional experiences and an individual’s personal experiences of
2013; Wright, addiction and recovery. (8 factors)
Zammuto, et al., 2016.
EBMgt Process (n= 3) EBMgt decision 1. Define and redefine practice questions, 2. Gather evidence, 3. Critically appraise evidence, 4. Engaging
McBride, 2015; Plath, making stakeholders and generating evidence based alternatives, 5. Committing to an evidence-based solution and
2014; Wright, implementation, 6. Evaluate EBMgt process and client outcomes. (6 factors)
Zammuto, et al., 2016.
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