Written by Martin Marshall, Lead for Improvement Science London and Professor of Healthcare Improvement at UCL.
First posted on Improvement Science London on October 23, 2012.
Many factors influence the decisions made by managers and clinicians about how best to organise and deliver healthcare. Scientific evidence has traditionally played a small part but this has the potential to change, aided by the emergence of the science of improvement.
People responsible for improving how we implement what we know are now facing a similar challenge to that faced by those providing clinical care 20 years ago. Prior to the advent of the Evidence Based Medicine (EBM) movement, clinicians often did what they did because they had always done it that way, or because their teachers told them to do it, or because it felt like the right thing to do. EBM challenged this, introducing a more systematic approach to clinical decision making which drew less on personal experience and more on rigorous and systematic research evidence. Is there anything that the nascent evidence-based management (EBMx, if you’ll excuse yet another acronym) movement can learn from the now mature EBM movement?
Ten years ago, David Naylor, a clinical academic from the University of Toronto, reflected back on the first decade of EBM and described four eras in its development. First, the era of optimism framed the problem as a lack of knowledge and the solution as promoting a better understanding of research, in the belief that passive diffusion of knowledge would make a difference. This was quickly followed by the second era, the era of innocence lost and regained, when the sheer volume of the literature became clear and we saw the emergence of evidence summaries in the form of guidelines. The disappointing uptake of guidelines led to the third era of industrialisation, in which a massive investment was made to purposefully and sometimes aggressively promote their use. And now we have entered the era of systems engineering, drawing on human factors learning and focusing on clinical decision making as a task, that, like any other form of ‘work’ needs to be made as easy as possible with the aid of information technologies.
Where do we place evidence-based management on this evolutionary pathway? Pessimists might claim that the movement is not so much nascent as barely conceived. There are a few optimists around (mea culpa) but not many. Even on a good day, optimists will acknowledge that the implementation literature is even more vast, amorphous, inaccessible and full of gaps than the clinical literature. Efforts have been made by some, most notably the NHS Confederation, the SDO (Service Delivery and Organisation) R&D programme, the Kings Fund and the nine CLAHRCs (Collaborations for Leadership in Applied Health Research and Care) across England, to produce evidence summaries in areas such as care integration and hospital mergers, but the impact of these efforts on the decision making process is at best uncertain.
Whilst the idea of industrialisation or systems engineering of implementation evidence feels like a long way off, this is precisely where we need to head, and quickly. The challenges of scaling up and systematising the use of implementation evidence are significant, given the nature of the evidence and the readiness of the decision makers to operate differently, but they are not insurmountable. The investments made by the National Institute for Health Research into knowledge mobilisation and a second round of CLAHRCs will help.
But perhaps the biggest challenge is that managerial decision making will always be different from clinical decision making. By its very nature, it will always be less rational, more political, more influenced by pragmatism and ideology. Whilst the use of evidence will improve the decision making process, it will never dominate it. So perhaps we need to think about an additional era in its evolution, an era that we might call enlightenment version 2.0. In the eighteenth century, the enlightenment movement promoted science over rationalism and authority. Version 2.0 doesn’t turn the clock back, so much as acknowledge that in some realms of life decision making is more complex, imperfect and irrational than in others. We desperately need good scientific evidence to inform management decisions, but perhaps we need to think more creatively about how to generate and mobilise that evidence.