Evidence-Based Approach to Health Care

¶ … Evidence-Based Approach to Health Care Management

The objective of this work is to assess the potential of an evidence-based approach to health care management. Toward this end this work will review the literature in this area of study.

Questions addressed in this research study include those of:

(1) How does evidence-based management compare with evidence-based medicine?

(2) Could an evidence based approach led to improvements in health care policy and practice or are there too many obstacles to its widespread use?

The work of Lewis and Latney (2003) entitled: "Achieve Best Practice With an Evidence-Based Approach" states that successful "...progressive care units (PCUs) operate in a benchmarking evidence-based practice environment and maintain strong interdisciplinary teams to efficiently measure outcomes." p.1 This approach is one that is accepted and utilized by major health care agencies and this includes the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

In health care, it is stated by Lewis and Latney (2003) that the terms benchmarking and best practice are defined as "...continuous, collaborative and systematic processes for measuring and examining internal programs' strengths and weaknesses. They are also commonly used to describe the data comparison for the purpose of learning about and adapting best clinical or operational practices." p.1 Best practice departments are those that exceed the national benchmark. Stated by Lewis and Latney (2003) to be a critical element of quality management programs is that of customer satisfaction which impacts "both business results and the community's image of care quality." p.2

The work of McCluskey and Cusick (2002) entitled: "Strategies for Introducing Evidence-Based Practice and Changing Clinician Behavior: A Manager's Toolbox" states that evidence-based practice is "a process which involves searching for, appraising, and then using research findings to guide clinical practice (Hamer, 1999 in McCluskey and Cusick, 2002) Evidence-based practice is also stated to be "...about using, rather than doing research." (Taylor, 2000 in: McCluskey and Cusick, 2002). p.2

The aim of the evidence-based practice is increasing "...clinical effectiveness." (McCluskey and Cusick, 2002) It is important to encourage effective interventions while discouraging those which are found to be ineffective or harmful. Evidence-based practice is a process that "encourages health professionals to identify client groups most likely to benefit from their services, and interventions most likely to produce positive outcomes." (Egan Dubouloz, von Zweck & Vallerand, 1998 in: McCluskey and Cusick, 2002). McCluskey and Cusick (2002) report that the benefits of the adoption of practices that are evidence-based have been "well documented in the...literature." p.2

McCluskey and Cusick (2002) report that the process of implementing evidence-based practice involves four specific steps and all of which make a requirement of new learning. Those four steps are as follows:

(1) formulation of clear clinical questions, preferably from a client's perspective;

(2) searching the literature for relevant scientific evidence;

(3) critically appraising the evidence; and (4) integrating the findings into practice and teaching. (McCluskey and Cusick, 2003, p.3)

Stated to be the final step and to qualify as a fifth step is the process of evaluation in which changes to the professional practice are monitored and reinforcement of the desired behaviors takes place. A primary challenge for managers is the coordination of the continuing skill acquisition and professional development that goes hand-in-hand with evidence-based practice. Toward this end, managers generally use regular performance appraisals and learning contracts.

Also needed are "...adequate supervision and mentoring" for the purpose of ensuring that the learning objectives of individuals are pursued diligently and that these are not continually postponed due to the stressors and pressures of work. McCluskey and Cusick (2003) state recommendations for a multifaceted approach in the ongoing professional development process in order to accommodate variations in learning styles and learning needs.

The work of Shortnell, Rundall and Hsu (2007) entitled "Improving Patient Care By Linking Evidence-Based Medicine and Evidence-Based Management" states that it was not until a century ago that a patient could actually expect to "benefit form the medical care provided by a typical physician. Today most patients benefits from medical care, but all patients could benefit if clinicians routinely provided care consistent with the latest scientific knowledge. One report suggests that only 55% of U.S. adults receive care consistent with current recommendations." (Shortnell, Rundall and Hsu, 2007, p.2)

It is also suggested in another report that "only in eight of 306 regions do physicians comply with evidence-based guidelines for at least 80% of their patients." (Shortnell, Rundall and Hsu, 2007, p.3) It is this that led to the Institute of Medicine concluding that there is a chasm "between the healthcare we have and the healthcare we should have." (Shortnell, Rundall and Hsu, 2007, p.2) Shortnell, Rundall and Hsu state that there are two components which are necessary for bringing about an improvement to the quality of medical care and that those two are:

(1) advances in evidence-based medicine (EBM) which identify the clinical practices leading to better care; and (2) the content of providing care and knowledge of how to put this content into routine practice. (Shortnell, Rundall and Hsu, 2007, p.3)

Shortnell, Rundall and Hsu state that these advances in evidence-based management "identify the organizational strategies, structures, and change management practices that enable physicians and other health care professionals to provide evidence-based care, i.e., the context of providing care." (2007, p.4)

Shortnell, Rundall and Hsu state that until both of these components are implemented the identification of the best content and application of it within the context of an effective organization the consistent and sustainable quality improvements in health care provided is not likely to occur. There must be an integration of the knowledge of "....what should be done evidence on which drug, medical device, procedure or treatment plan is most likely to improve patient outcomes needs to take into account the organizational and community context in which the care is delivered." (Shortnell, Rundall and Hsu, 2007, p.4)

It is additionally reported that randomized clinical trails that emphasize internal validity are the gold standard for creating EBM, but have limited generalizabilty to patients, providers and treatment settings different from those in the RCTs." (Shortnell, Rundall and Hsu, 2007, p.4)

It is stated that in excess of 90 million individuals in the United States have at least one chronic condition; many have more than one, and chronic conditions account for nearly 75% of all healthcare expenditures." Factors associated with better outcomes for patients include the following:

(1) disease registries;

(2) clinical guidelines;

(3) automatic reminder systems;

(4) system redesign processes;

(5) physician feedback reports; and (6) patient self-management education programs. (Shortnell,

Rundall and Hsu, 2007, p.7)

The problem however, is stated to be that in practices with twenty or more physicians in the U.S. "on average use fewer than half of the recommended chronic care model elements when caring for patients with asthma, congestive heart failure, depression and diabetes, and only 1% of such practices use all recommended elements for all four conditions." (Shortnell, Rundall and Hsu) Conclusions and recommendations stated in the work of Shortnell, Rundall and Hsu (2007) include the following points:

(1) The nexus of EBM and EBMgt represents an important frontier for improving the nation's health care system. Given the likely increased demand for better and measurably valuable care, combined with increasing cost and quality pressures and calls for health care reform, the following suggestions may be helpful for promoting the integration of EBM and EBMgt and for reducing the barriers to their use;

(2) The federal government should establish a National Evidence-based Healthcare Management Center. For example, the Agency for Health Research and Quality (AHRQ) could extend its Evidence-Based Practice Centers initiative with input from the National Quality Forum, and related groups. The program's primary responsibilities would be to ensure that management/organizational research is rigorously assessed and synthesized in meta-analyses; made widely available in usable forms for managers and clinicians; and effectively linked to other evidence-based management and medicine repositories.

(3) Health networks should be expanded, such as AHRQ's Accelerating Change and Transformation In Organizations and Networks (ACTION). This network involves partnerships of hospitals, health plans, providers, and researchers to address questions regarding the scientific evidence on what does and does not work to improve care in real-world settings.

(4) External accreditation, certification, and licensing bodies should look for "evidence" of EBM and EBMgt linkages in their reviews. (Shortnell, Rundall and Hsu, 2007, p.8)

Shortnell, Rundall and Hsu conclude by stating that recommendations for practice, policy and interventions are needed in providing better patient care through combining content and context of care because only an approach that is integrated and evidence-based can bring about a reduction in the quality gap and instill greater confidence in the U.S. healthcare system." (2007, p.9)

Yassi, Ostry, Spiegel, and Walsh (2002) entitled: 'A Collaborative Evidence-Based Approach to Making Healthcare a Healthier Place to Work" published in the Hospital Quarterly states that healthcare providers and administrators are the "backbone of the healthcare system." (Yassi, Ostry, Spiegel, and Walsh, 2002, p.1) They are stated to be specifically trained in promoting good health, "to care for and comfort the sick, to expand what we know about health and healthcare and to improve the effectiveness of the way the healthcare system functions... If one of the goals of the healthcare system is to promote health and prevent illness and injury, it may be logical to start with those who work in the system." (Yassi, Ostry, Spiegel, and Walsh, 2002, p.1)

Presently the healthcare environment is characterized by nurse shortages of 25% of the entire nursing force. It is held that the working conditions along with job stress negatively impact the nursing force and its turnover rate. Injuries are also reported by nursing staff. It is likely that the nursing shortage is the number one challenge in today's healthcare provision. The negative work environment negatively impacts the nursing professional and their decision to either leave or to potentially fail altogether to enter the profession.

Naturally when there is a shortage of any type of professional worker some area suffers their absence and when this concept is applied in the field of healthcare provision it is certain that the outcomes for the patient/consumer is negatively impacted. Therefore, it would appear that management that is based in evidence and specifically from this the view expressed in the work of Yassi, Ostry, Spiegel, and Walsh (2002) is that the role of the nurse is so very critical and vital to patient outcomes that the starting point of evidence-based practice is in the area of management of the healthcare provider workforce. (2002, paraphrased)

The work of Rundall (2002) entitled: "Evidence-Based Management in Healthcare: Lessons from Clinical Practice: reports a research study that had as its objective the development of an analytic framework for comparison of decision-making processes in clinical practice to those in health management and policy arenas, and to explore the potential for the development of evidence-based approaches to health management and health policy." (Rundall, 2002, p.1)

Rundall states that the study was based on an extensive review of the relevant literature. (2002, p.1) Evidence-based clinical practice is stated by Rundall (2002) to have "made great strides and important changes in the way clinicians make decisions..." (p.1) Additionally stated is that the managers and policymakers "have been prominent advocates of evidence-based clinical practice, but have not been quick to apply the same principles to their own decision making. When health policy development and managerial practice are examined, it is evident that many examples of a research/practice gap can be identified. The appropriate use of research evidence in management and policy decision making could improve quality and performance in health systems, but important differences in the culture, research base and decision making process exist and need to be taken into account." (Rundall, 2002, p.1) Rundall (2002) concludes by stating that if "...a more evidence-based approach to health management and policy making is to develop, concerted action is needed by a range of stakeholders including government agencies, health care organizations, research funders, academic centers and professional associations. Firstly, cultural and attitudinal change is needed, which can be brought about through a range of measures aimed at closing the gap between managers and policy makers on the one hand and researchers and academics on the other. Secondly, government agencies and research funders need to invest in developing the infrastructure to support evidence-based decision making." (Rundall, 2002, p.1)

Implications stated by Rundall (2002) for policy, delivery or practice is as follows: "In the long-term, concerted action by key stakeholders in the healthcare system would help to develop a cadre of managers and policy makers with the skills, systems and support needed to use evidence more effectively in their own decision making and to support the development of evidence-based clinical practice. Such developments would be likely to result in improvements in healthcare quality and health system performance." (Rundall, 2002, p.1)