Evidence-based management reconsidered

Reports of medical mistakes have splashed across newspapers and magazines in the United States. At the same time, instances of overuse, underuse, and misuse of management tactics and strategies receive far less attention. The sense of urgency associated with improving the quality of medical care does not exist with respect to improving the quality of management decision making. A more evidence-based approach would improve the competence of the decision-makers and their motivation to use more scientific methods when making a decision. The authors of this article consider a study of 68 U.S. health services managers that found a low level of evidence-based management behaviors. From the findings, four strategies are suggested to increase health systems managers' use of research evidence to improve decision making: focusing evidence-based decision making on strategically important issues, developing committees and other structures to diffuse management research throughout the organization, building a management culture that values research, and training managers in the competencies required to apply research evidence to health services management decisions. To aid the manager in understanding and applying an evidenced-based approach to decision making, the article provides practical tools, techniques, and resources for immediate use.     

Trust between managers and physicians in community hospitals: the effects of power over hospital decisions

Trust is a key element of effective work relationships between managers and physicians. Despite its importance, little is known about the factors that promote trust between these two professional groups. We examine whether manager and physician power over hospital decisions fosters manager-physician trust. We expect that with more power, managers and physicians will have greater control to enforce decisions that benefit the interests of both groups. Subsequently, they may gain confidence that their interests are supported and have more trust for each other. We test proposed hypotheses with data collected in a national study of chief executive officers and physician leaders in community hospitals in 1993. Findings indicate that power of managers and physicians over hospital decisions is related to manager-physician trust. Consistent with our expectations, physicians perceive greater trust between the two groups when they hold more power in four separate decision-making areas. Our hypotheses, however, are only partially supported in the manager sample. The relationship between power and trust holds in only one decision area: cost/quality management. Our findings have important implications for physician integration in hospitals. A direct implication is that physicians should be given the opportunity to influence hospital decisions. New initiatives, such as task force committees with open membership or open forums on hospital management, allow physicians a more substantial involvement in decisions. Such initiatives will give physicians more "voice" in hospital decision making, thus creating opportunities for physicians to express their interests and play a more active role in the pursuit of the hospital's mission and objectives.     

Administrative decision making: a stepwise method

Today's health care organizations face tremendous challenges and fierce competition. These pressures impact the decisions that managers must execute on any given day, not to mention the ever-present constraints of time, personnel, competencies, and finances. The importance of making quality and informed decisions cannot be underestimated. Traditional decision making methods are inadequate for today's larger, more complex health care organizations and the rapidly changing health care environment. As a result, today's health care managers and their teams need new approaches to making decisions for their organizations. This article examines the managerial decision making process and offers a model that can be used as a decision making template to help managers successfully navigate the choppy health care seas. The administrative decision making model will enable health care managers and other key decision makers to avoid the common pitfalls of poor decision making and guide their organizations to success.     

Are decisions by purchasers in an English health district evidence-based?

OBJECTIVES: First, to investigate how many decisions by one commissioning body (district health authority) were based on evidence of effectiveness from randomised controlled trials (RCTs) and systematic reviews of RCTs. Second, to investigate whether other types of quantitative studies and qualitative studies could be used as evidence to support commissioning decisions. METHOD: From three planning documents (for 1997-1998), all statements were identified. Effectiveness questions were constructed from each and used to search for evidence from trials and reviews in the Cochrane Library (Issue 4, 1998). Further searches for other studies (all methodologies) were performed on a subset of decisions and appraised by an independent expert panel. RESULTS: A total of 124 decisions were identified of which two-thirds concerned organisation of care. Evidence existed for less than half (48.4%) the decisions, with 33.9% favouring the decision and 14.5% where evidence was either equivocal or unfavourable. From a random subset of ten decisions, relevant non-randomised quantitative studies and qualitative studies were identified for half the decisions. Evidence from economic evaluations was identified for only one decision. CONCLUSIONS: Large gaps in knowledge exist if health care purchasers are to base their decisions on evidence of effectiveness from RCTs. However, other types of evidence can be used to support such decisions. Summaries of research should be published in a format that is accessible to purchasers.     

Factors affecting the utilization of systematic reviews. A study of public health decision makers.

OBJECTIVE: To determine the extent to which public health decision makers used five systematic reviews to make policy decisions, and to determine which characteristics predict their use. METHODS: This cross-sectional follow-up study of public health decision makers in Ontario collected primary data using a telephone survey and a short, self-administered organizational demographics questionnaire completed by the administrative assistant for each Medical Officer of Health. Independent variables included characteristics of the innovation, organization, environment, and individual. Data were entered into a computerized database developed specifically for this study, and multiple logistic regression analysis was conducted. RESULTS: The participation rate was very high, with 85% of public health units and 96% of available decision makers completing the survey. In addition, 63% of respondents stated they had used at least one of the systematic reviews in the previous 2 years to make a decision. The most important predictors of use were one's position, expecting to use a review in the future, and perceptions that the reviews were easy to use and that they overcame the barrier of limited critical appraisal skills. CONCLUSIONS: Utilization of the systematic reviews in Ontario was very high. The utilization rates found in this study were significantly higher than those reported in previous utilization studies. One's position was found to be the strongest predictor of use, identifying program managers and directors as the most appropriate audience for systematic reviews.     

Use of Coercive Sexual Tactics Across 10 Years in At-Risk Young Men: Developmental Patterns and Co-occurring Problematic Dating Behaviors

Men’s use of two coercive sexual tactics was tracked over 10 years in a sample of at-risk young men (N = 201). Patterns were identified for each tactic. For the tactic using drugs or alcohol to go further sexually, non-coercers (63%) and coercers (37%) were identified. For the tactic of going further sexually after the woman said “no,” three patterns were identified—noncoercers (10%), low-level coercers who used the tactic five times or less over 10 years (42%), and high level coercers who used the tactic more than five times over 10 years (48%). The associations between coercive tactics and two dating behaviors—physical aggression toward a partner and risky sexual behaviors—were examined using multilevel linear modeling. For both coercive tactics, main effects and interaction effects with time occurred for physical aggression toward a partner. The most coercive men perpetrated the most physical aggression toward a partner between ages 18 and 22 years, but sexual coercion was unrelated to partner abuse between ages 22 and 27 years. Results suggest men vary in their use of coercive sexual tactics over time and the frequency of coercion varies based on tactic. Preliminary evidence suggests the use of coercive sexual tactics is associated with physical aggression toward a partner but not risky sexual behaviors, though the strength of the association varies over time.     

Dynamic Assessment in Disease Management

The effectiveness of disease management programmes hinges on a combination of factors, all of which are important to consider when selecting a programme for implementation. This article provides a brief overview of disease management programmes commonly found in healthcare organisations, highlighting the issue of programme effectiveness.Seven factors critical to the design and development of an effective disease management programme are outlined to guide practitioners and healthcare managers who are responsible for making decisions about such programmes. These decision factors are: (i) defining and establishing programme goals; (ii) defining a target population; (iii) selecting measures of programme success; (iv) determining data availability and information systems capability; (v) deciding to build or buy all or parts of a programme; (vi) determining and enhancing the level of physician involvement; and (vii) selecting strategies to enhance organisational support. Careful consideration of these factors in the decision stage for a disease management programme will help ensure effective and appropriate programme development and implementation. Healthcare managers applying these considerations will be better able to develop disease management programmes that achieve their objectives and provide a foundation for organisational success.     

Beyond evidence: a retrospective study of factors influencing a malaria treatment policy change in two South African provinces

There is a growing appreciation that decisions on changing drug treatment policy should be based on robust evidence of drug effectiveness. No published information describing the process of decision making prior to malaria treatment policy changes or subsequent success in implementing treatment policy changes exists in South Africa. This retrospective study of the differential implementation of a policy change from chloroquine to sulphadoxine-pyrimethamine for first-line treatment of malaria in two South African provinces, Mpumalanga and Limpopo Province, sought to explore the change from the perspective of national and provincial policy makers and programme managers. Focus-groups discussions, in-depth interviews, participatory exercises and archival documentary analysis were conducted. Policy makers and programme managers mentioned the need for local efficacy data as a prerequisite for changing malaria treatment policy. However, drug efficacy data alone were not sufficient to ensure effective policy making or implementation in this study. An effective strategy identified for motivating a change in policy was emphasizing the potential negative consequences of failure to implement a treatment change. In both provinces it was recognized that, for a policy change to be successful and applied at peripheral levels, the proposed change had to have official sanctioning from credible sources. Physical removal of all previously recommended medication from public healthcare facilities appeared to be a key factor in ensuring successful implementation. Lessons learnt through this retrospective analysis may be of value to a number of countries in sub-Saharan Africa, considering policy change in response to rapidly increasing anti-malarial drug resistance. However, additional case studies of the process of malaria treatment policy change are urgently needed from other African settings to determine commonalities and optimize the efficiency of formulating and implementing malaria treatment policy changes.     

Doctor-manager relationships in the United States and the United Kingdom

In many developed countries, including the United States and the United Kingdom, the relationships between doctors and hospital managers are strained. The purposes of this article are to examine survey data from the United States and the United Kingdom on doctor-manager relationships and to identify the sources of strain common to both countries as well as those particular to each country's health system. The two countries exhibited many similarities. A very high proportion of respondents from both countries identified external factors-such as governmental budget cuts, pressure from third parties to increase physicians' workload, and the turbulence of the policy environment-as important barriers to improving doctor-manager relationships. Other common sources of strain were concerns over resource availability and the relative power of doctors and managers. Sources of relationship tension particular to each country were also found. Substantial divergence of opinion was expressed with respect to internal factors that affect doctor-manager relationships. Respondents from the United States were more negative than those from the United Kingdom in their ratings of teamwork and communication between doctors and managers, and they were also less likely to have confidence in the medical staff. Respondents from the United Kingdom were more likely to believe that hospital management is driven more by financial than clinical priorities. Managers can implement several strategies to improve doctor-manager relationships, including greater organizational transparency in decision making; more frequent communication between managers and doctors; and more physician involvement in decision making, especially with regard to important resource-related decisions, and in organizational governance.     

Development of instruments to measure the quality of breast cancer treatment decisions

Background Women with early‐stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients’ knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality. Objective To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. Methods Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross‐sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined. Results Thirty‐eight facts (11–14 per decision) and 27 goals (8–10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. Conclusions Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients’ and providers’ perspectives are different, it is vital that instrument development should include items reflecting both views.     

Suitability of Preference Methods Across the Medical Product Lifecycle: A Multicriteria Decision Analysis

ObjectivesThis study aimed to understand the importance of criteria describing methods (eg, duration, costs, validity, and outcomes) according to decision makers for each decision point in the medical product lifecycle (MPLC) and to determine the suitability of a discrete choice experiment, swing weighting, probabilistic threshold technique, and best-worst scale cases 1 and 2 at each decision point in the MPLC.MethodsApplying multicriteria decision analysis, an online survey was sent to MPLC decision makers (ie, industry, regulatory, and health technology assessment representatives). They ranked and weighted 19 methods criteria from an existing performance matrix about their respective decisions across the MPLC. All criteria were given a relative weight based on the ranking and rating in the survey after which an overall suitability score was calculated for each preference elicitation method per decision point. Sensitivity analyses were conducted to reflect uncertainty in the performance matrix.ResultsFifty-nine industry, 29 regulatory, and 5 health technology assessment representatives completed the surveys. Overall, “estimating trade-offs between treatment characteristics” and “estimating weights for treatment characteristics” were highly important criteria throughout all MPLC decision points, whereas other criteria were most important only for specific MPLC stages. Swing weighting and probabilistic threshold technique received significantly higher suitability scores across decision points than other methods. Sensitivity analyses showed substantial impact of uncertainty in the performance matrix.ConclusionAlthough discrete choice experiment is the most applied preference elicitation method, other methods should also be considered to address the needs of decision makers. Development of evidence-based guidance documents for designing, conducting, and analyzing such methods could enhance their use.     

DECIDE: a decision-making model for more effective decision making by health care managers

The purpose of this article is to describe a step-by-step process for decision making, and a model is developed to aid health care managers in making more quality decisions, which ultimately determines the success of organizations. The DECIDE model is the acronym of 6 particular activities needed in the decision-making process: (1) D = define the problem, (2) E = establish the criteria, (3) C = consider all the alternatives, (4) I = identify the best alternative, (5) D = develop and implement a plan of action, and (6) E = evaluate and monitor the solution and feedback when necessary. The DECIDE model is intended as a resource for health care managers when applying the crucial components of decision making, and it enables managers to improve their decision-making skills, which leads to more effective decisions.     

Dental students' treatment of anxious patients

Patients' anxiousness over treatment is an important factor in the utilization, delivery, and outcome of health care. Patient anxiety over dental treatment is widespread and is a source of stress for both patients and dentists. This paper reports a study of how dental students cope with fearful patients they treat during training, and what tactics they believe are effective. Two classes of senior dental students at a state university (n = 127) completed a brief questionnaire that asked them to describe what they had done in a previous encounter with a nervous patient, and to assess the effect of their actions. Students estimated that almost a quarter of their patients were anxious; most believed that they themselves were made nervous by such patients. Virtually all were committed to using talk plus local anesthesia rather than more extensive, drug-oriented methods. The coping repertoire was extensive. Giving reassurance was the most prominent tactic, followed by providing information about the procedure; expressing empathy or identifying patient feelings and the source of fear; and presenting a calm manner. Most students believed their actions had at least some positive, if not a dramatic, effect. In rating the effectiveness of 10 actions a dentist can take to deal with patient anxiety, the large majority of students rated every behavior as being at least somewhat effective. The behaviors rated 'very effective' by half or more of the students included having a calm manner, demonstrating that what the patient says is taken seriously, being friendly, making the patient feel welcome, and giving moral support during the procedure.     

Are economic evaluations and health technology assessments increasingly demanded in times of rationing health services? The case of the Argentine financial crisis

OBJECTIVES: After 4 years of deepening recession, Argentina's economy plummeted after default in 2002. This crisis critically affected health expenditures and triggered acute rationing. Our objective was to explore health decision-makers' knowledge and attitudes about economic evaluations (EE) and whether health technology assessment (HTA) were increasingly used for decision making. METHODS: A qualitative design based on semistructured interviews and focus groups was used to explore how decision makers belonging to different health sectors implement resource allocation decisions. RESULTS: Informants were mostly unaware of EE. The most important criteria mentioned to adopt a treatment were evidence of effectiveness, social/stakeholder demand, or resource availability. Despite general positive attitudes about EE, knowledge was rather limited. Although cost considerations were widely accepted by purchasers and managers, clinicians argued about these issues as interfering with the doctor-patient relationship. Other important perceived barriers to HTA use were lack of confidence in the transferability of studies conducted in developed countries and institutional fragmentation of the Argentine healthcare system. The new macroeconomic context was cited as a justification of implicit rationing measures. Although explicit priority setting was implemented by many purchasers and managers, HTA was not used to improve technical and/or allocative efficiency. CONCLUSIONS: The crisis seems to be a strong incentive to extend the use of HTA in Argentina, provided decision makers are aware as well as involved in the generation of local studies.     

普通中学管理者参与式艾滋病教育培训效果评价

目的提高学校领导者对预防艾滋病健康教育重要性的认识,加强学校预防艾滋病教育的力度,探讨有效、可行的学校领导培训模式。方法在黑龙江省和河南省举办为期1d的普通中学领导培训班各1期。采用参与式教学方法,以国家相关政策和反对歧视的理念为切入口,培训学校管理人员、校医和中小学保健所管理人员共78人。评价培训后的效果。结果培训后学员知识水平显著提高,态度明显转变,普遍认识到在学校开展预防艾滋病健康教育的重要性和紧迫性。互动式培训模式深受学员欢迎,学员对培训内容的有效性及发放教学材料等方面评价较高。结论加强学校领导预防艾滋病教育的培训是落实国家及教育部门相关政策的关键。参与式培训模式是有效且可行的,可以推广应用。     

Working capital management policy in health care: The effect of leverage

Hospitals, which are mainly capital intensive, require large amounts of financial resources to render high-quality services. Accordingly, health care managers and policy makers should take into account the level of debt in managing working capital. This study, therefore, aims to explore whether the financial leverage moderates the relationship between the working capital and profitability for the publicly-listed European Hospitals. The data set including 52 hospitals with 468 observations was solicited from the ORBIS. A regression analysis was carried out. The results reveal that increasing the length of the cash conversion cycle for hospitals with high financial leverage decreases profitability. On the contrary, increasing the length of the cash conversion cycle for the ones having low leverage boosts profitability. The findings of this study suggest that since leverage influences the relationship between the cash conversion cycle and profitability, the degree of financial leverage is an important indicator to be considered by health care managers and policy makers in managing working capital. In addition, by clarifying the effect of leverage, this study helps policy makers understand and estimate the possible impact of working capital changes on profitability. This study also helps managers and decision makers not only apply a tight working capital policy but also decide whether to increase or decrease the length of cash conversion cycle to improve hospital profitability.     

Opinions of primary care managers on sources of influence on medical practice. Differences with physicians' opinions

OBJECTIVES: To determine the opinion of primary healthcare managers on the importance and legitimacy of different sources of influence in medical practice, and to compare the results with the opinions of physicians in healthcare teams. MATERIAL AND METHODS: Design: cross-sectional study. Population: primary healthcare managers in the Spanish public health system (area managers, medical and nursing directors) and in the Andalusian health service (district director, nursing coordinators and epidemiology and program coordinators). The sample comprised the total population of 302. As dependent variables, a series of questions was designed to gather the interviewees' opinions on different strategies, institutions and/or collectives that exert some kind of influence on medical practice. The degree of importance of each factor was summarized into a set of 9 items. The subjects were asked to score each item from 1 (most important) to 9 (least important). To assess the legitimacy of these scores, 16 items were presented measured using a Likert-type 7-point scale (1: not at all legitimate; 7: very legitimate). A self-administered questionnaire was used, sent by mail. Non-parametric tests (Friedman and Kruskall-Wallis) were used for statistical analysis of the data. RESULTS: The response rate was 79.8%. Using the Friedman test for an ordinal 9-point scale, analysis of the mean ranges for each item revealed that the most important sources of influence for the primary healthcare managers interviewed were: the devising of management protocols by the doctors themselves; discussion with colleagues; feedback from patients, and attending training courses, and reading articles and scientific journals. The institutions or groups with the greatest legitimacy to influence medical practice were: users or citizens; internal audits; peers; scientific associations, and the managers themselves. CONCLUSIONS: The sources of influence considered to have the greatest importance and legitimacy in influencing medical practice concern the professional medical system (self-defined protocols, discussion with colleagues, etc.). Managers accept the use of business managerial tools as well as the influence of social actors to a greater extent than do physicians. This finding could indicate differences in the value systems between primary healthcare physicians and managers.     

Hospital choice factors: a case study in Turkey

In an attempt to test the robustness of the numerous American findings related to hospital choice in the context of another country, this study examines the factors affecting hospital choice decisions of 869 patients in three public and one private hospital policlinics in Ankara, Turkey and attempts to determine their importance levels. Identification of these factors and determining their effect levels is important in concentrating management efforts on these key areas and in formulating effective marketing strategies to retain and expand hospital patient bases in the future. Our findings highlight the importance of accessibility of hospital services to consumers in hospital choice as well as the role of hospital's image, its physical appearance, and technological capabilities in informing such choices. American health care managers can use these findings to further understand how patients make choices related to health care facilities and to develop marketing strategies that may more effectively market their facilities.     

Perceptions of team workers in youth care of what makes teamwork effective

In youth care, little is known about what makes teamwork effective. What is known mostly reflects the view of managers in care organisations, as objective outcome measures are lacking. The objective of this article was to explore the views of youth care workers in different types of teams on the relative importance of characteristics of teamwork for its effectiveness. Q methodology was used. Fifty-one respondents rank-order 34 opinion statements regarding characteristics of teamwork. Individual Q sorts were analysed using by-person factor analysis. The resulting factors, which represented team workers' views of what is important for effective teamwork, were interpreted and described using composite rankings of the statements for each factor and corresponding team workers' explanations. We found three views of what makes teamwork effective. One view emphasised interaction between team members as most important for team effectiveness. A second view pointed to team characteristics that help sustain communication within teams as being most important. In the third view, the team characteristics that facilitate individuals to perform as a team member were put forward as most important for teamwork to be effective. In conclusion, different views exist on what makes a team effective in youth care. These views correspond with the different types of teams active in youth care as well as in other social care settings.