Gestão da Saúde Baseada em Evidências

Evidence-Based Management in Healthcare

Bruce Fried, PhDDepartment of Health Policy & Administration

University of North Carolina at Chapel HillJune 4, 2008

The Problem:

Poor quality of management in health care

As educators, we have great hopes for our students and for improvements in health management

The Great Hope

Through research and education . . .

• Managers will make less arbitrary and more reflective decisions

• Managers can better fulfill the aspirations they have for themselves

The Great Disappointment

• Research on management effectiveness does not transfer well to the workplace

• Managers rely on personal experience with no real evidence

• Managers follow bad advice on weak evidence

Specifically, on what basis do managers make decisions?

• Do they make their decisions based on the best research?

• Do they even know that there is research about management?

• Or are managers too busy to see all of the evidence that may influence a decision?

Managers face constraints in how they use information.

Bounded Rationality

We are also constrained in our ability to process information.

On the following page you will see two upside-down smiling faces

Raise your hand if you see two upside down smiling faces.

A BRIEF EXPERIMENT

Now we will turn the images facing in the correct direction.

The Lesson: Bounded Awareness

• We see what we expect to see and ignore other possibilities.

• Our understanding is bounded by our expectations and past experiences – not evidence!

“Bounded Awareness” can have serious consequences

• We may fail to seek out important information

• We may fail to use information because we don’t know it is relevant

• We may fail to share the information with others

The Challenger disaster

Failure to seek out important information

Failure to use information because we fail to see its relevance.

Jésica Santillán before the operation

Jésica Santillán after the operation

The avoidable outcome: Failure to share information

When we talk about evidence-based management, this is not just a management exercise.

Poor Management Can Kill

Evidence-Based management: Using what we know

The evidence-based movement is not new

• Policing• Education • Medicine • Nursing

Evidence-based practice is paradigm for making decisions that mobilizes cause-effect

knowledge to guide practice toward more desirable results.

Can we learn from the experience of evidence-based medicine?

It is clear that evidence in medicine is under-used.

The Knowledge-Practice Problem or the “Knowing-Doing Gap”

Wrong assumption:

Promising new interventions with proven efficacy will be quickly and universally translated and offered to clients who might benefit from them

The reality:

In the real world, translation of science-based practices stumble, largely unguided, toward uneven, incomplete and socially disappointing outcomes.

Awareness = Adoption

Knowledge = Practice

Evidence-based medicine: mixed results

• As many as 98,000 people die each year in American hospitals due to medical errors -- more than auto accidents, breast cancer, or HIV AIDS.

• The Institute for Health Improvement estimates that nearly 15 million instances of medical harm occur in the US each year – a rate of over 40,000 per day. 

Variations in spending for health care unrelated to health status

Medicare Spending per Beneficiary, by Hospital Referral Region, 2005

Research show variations in care by geographic region

• Vaccination for pneumococcal pneumonia • Mammography screening for breast cancer • Screening for colon cancer • Eye examinations for diabetics • HgA1c monitoring for diabetes • Blood lipid monitoring for diabetes • Prescription of aspirin therapy for heart attack victims • Prescription of beta-blockers for heart attack victims • Prescription of ACE inhibitors for heart attack victims • Early reperfusion with thrombolytic agents and • Percutaneous transluminal coronary angioplasty for

heart attack victims.

The Pioneer

Jack Wennberg, Dartmouth Medical School

The Development of Evidence-Based Medicine

• Unexplained wide variations in clinical practice patterns

• Poor uptake of therapies with known effectiveness

• Persistent use of technologies that were known to be ineffective

Three categories of problems: overuse, underuse, and misuse

Overuse

• Caesarean Section

• Routine tonsillectomy

• Surgical weight-loss

• Back surgery

Underuse

• Use of physician substitutes

• Smoking cessation through nicotine replacement therapy

• Repeat colonoscopy for high-risk patients

• Intrauterine contraceptive devices in developing countries

• Childhood immunizations

Misuse

• Off-label use of drugs

• Antibiotics

• Incorrect dosing for treatment of psychiatric disorders

• Magnetic Resonance Imaging (MRI)

Why is evidence-based medicine difficult to implement?

• Volume of research evidence• The speed with which new evidence is created• The complexity of large healthcare

organizations• The practical difficulties in changing clinical

practice

Organizational or management interventions may be key to

implementing evidence-based medicine.

The Translational Research Movement

• Bench scientists often do not consider how their research might ultimately be used.

• Clinical scientists and health services researchers may lack the skills to translate strategies with demonstrated efficacy into the “real world.”

Researchers often do not know how to disseminate efficacious strategies.

Two Types of Translational Research

Translational research encourages partnerships between

researchers, practitioners, and people skilled in translation.

Bench Bedside

Type 1 Translational Research

Bedside Practice

Type 2 Translational Research

Type 1 Type 2

Translational Research is NOT Unidirectional: There are Feedback Loops

There are problems implementing evidence-based medicine.

But the problems are even more severe when we try to implement

evidence-based management.

What is Evidence-Based Management?

• Using evidence about cause and effect relationships (or probabilities)

• Building decision supports to promote evidence-based practices

• Information-sharing to reduce under-use, over-use, and misuse

Translating principles based on best evidence into organizational practices.

Links Between Management Practices and Research?

• Wide variations in managerial practice patterns

• Poor uptake of management practices of known effectiveness

• Persistent use of practices known to be ineffective

The result is a Research-Practice Gap

Similar to medicine, in management we see:

Important Differences Between Medicine and Management

• Medicine: Knowledge culture; high status to researchers

• Managers are skeptical of researchers and research findings

• Managers lack a common vocabulary

• Personal experience plays a larger role in management

Evidence-Based Management

• Slower to take hold

• Similar problems of overuse, underuse, and misuse

How Decisions Are Made

Medicine

Decisions made daily, usually without constraint

Decisions involve applying a body of knowledge to specific circumstances

Long tradition of using decision support systems

Results of decisions often very clear; feedback is sometimes immediate

Management

Fewer, larger decisions usually with groups requiring negotiation

Decision not necessarily based on a body of knowledge

No tradition of using decision support

Results of decisions often difficult to determine

But there is evidence that can be used to support management decision-making?

• Core Business Processes and Transactions

• Operational Management

• Strategic Management

If this is such a good idea, why is Evidence-Based Management so difficult to implement?

• Managers may feel threatened: management as an “art.”

• Decisions may be forced on them by stakeholders; incentives may not promote evidence-based approaches

• The “uniqueness paradox” – we’re different

The Management Personality

• Managers tend to manage in the manner in which they were managed

• Managers attracted to “quick fixes” and fads

• Doing what seems to have worked well in the past

• Following deeply held yet unexamined ideologies

How our teaching may contribute to the problem

• Do we keep up with changes in the body of knowledge?

• Do we teach what is need or do we teach what we learned?

• Students prefer “ready-to-use” solutions to current problems

• We often neglect to teach the principles behind solutions

Solutions for training

• Students need to know that management requires a sound foundation and years of practice and application

• Provide models of evidence-based management

• Promote use of evidence: need a balance between teaching principles (cause and effect knowledge) and practices (solutions to organizational problems)

• Actually using evidence requires a meta-skill: turning evidence-based principles into solutions

What is “evidence” in management? Some examples

Effective management strategies supported by evidence

Employment Security

Employment security encourages people to take a longer-term perspective on their jobs and organizational performance.

Selective Hiring of New Personnel

• Clarity about the most important skills and attributes.

• Skills and attributes should support the organization’s mission.

High Compensation Linked to Performance

• Paying high wages reduces turnover and facilitates organizational performance.

• Use organizational, team and individual rewards.• When employers are treated like owners, they act

and think like owners.

Extensive Training

• Enhances employee flexibility; helps organizations adapt to change.

• Training should include more than a narrow focus on job skills.

• The paradox of training: organizations train

in “good” times and abandon training in

“bad” times.

Reduced Status Distinctions

• Status distinctions make certain employees feel less valued (particularly in health care).

• Reduce symbolic and real status differences.

Extensive Information Sharing

• Sharing information sends a message that employees can be trusted.

• To improve performance, employees need information.

Self-Managed Teams and Decentralization

• Health care is a team activity.

• Teams permit employees to pool their ideas to come up with better solutions to problems.

I looked for photos of teams that would be familiar in Brasil.

NOT A GOOD PHOTO!

NOT A GOOD PHOTO!

SUCCESS!!

Obrigado!