More than 'using research': the real challenges in promoting evidence-informed decision-making

This paper summarizes Phase 1 results of From Evidence to Action, a project that explored perspectives of Regional Health Authority (RHA) planners and decision-makers on the nature of “evidence,” the use of evidence in decision-making and barriers to evidence-informed decision-making (Bowen and Erickson 2007). From Evidence to Action (funded by the Canadian Institutes of Health Research, 2005–2008) evolved from our earlier CIHR-funded The Need to Know project, which engaged researchers at the Manitoba Centre for Health Policy, the Department of Health and Manitoba RHAs in creating new knowledge of relevance to RHAs, increasing capacity and disseminating and applying research findings. The evaluation component of this project highlighted the importance of not simply involving individuals in capacity building and research activities, but of addressing organizational barriers to research use in RHA planning and decision-making – of moving from evidence to action (Bowen et al. 2005; Bowen and Martens 2006). There is an emerging literature providing evidence on the optimal management of people and performance in health services organizations (Michie and West 2004). Studies have identified organizational factors – such as employee involvement, creation of a learning culture and institution of good management – that promote better decision-making, as revealed in improved organizational performance (Bradley et al. 2004; Mitton and Patten 2004; Michie and West 2004; Carney 2006). As well, although there is lack of consensus on the concept of organizational culture (Scott et al. 2003), some studies have suggested that the culture of senior management affects health system performance (Gerowitz et al. 1996; Mannion et al. 2005). Mitton and Patten (2004) identified management operations as a factor in managers' ability to apply evidence effectively. Some studies have also explored what types of research are most likely to be utilized by decision-makers; for example, social science research appears to face greater barriers to utilization than natural science research (Hanney et al. 2003). On the other hand, research considered to be part of a larger policy trajectory and linked with broad organizational agendas (such as improving patient safety) may be more likely to be used (Lavis et al. 2002; Rosenheck 2001). However, compared to the large body of research on evidence-based clinical decision-making, there has been little research on evidence-informed management (CHSRF 2004; Lavis et al. 2002; Walshe and Rundall 2001). Past research has identified both similarities and differences in the barriers to using evidence in clinical versus policy and planning decisions. For example, time and workload, user capacity and evidence availability emerge as key factors in both forms of decision-making. However, there are important differences between clinical and management decision-making in culture, research base and decision-making processes (Walshe and Rundall 2001). In addition, organizations are complex, different kinds of decisions are made at different levels and many types of evidence may be used (Lomas 1990; Lavis et al. 2003; Walshe and Rundall 2001). Because RHAs are responsible for the implementation of policies and allocation of resources within a framework established at the provincial level, they can be seen as making decisions at the administrative policy level as well as at various program planning levels. Decisions may be related to core business transactions, operational management or strategic management (Kovner and Rundall 2006). Decision-making at the RHA board level should focus on strategic management; however, there may be considerable variability among boards in types of decisions made and the extent to which these decisions are informed by senior management. Another source of complexity is the multiplicity of types of evidence that decision-makers might weigh. It is increasingly recognized that “evidence” in planning and policy decisions must include more than research, and that such factors as resource availability, political context, values, client/community experience, clinical expertise and context-specific evidence such as performance measurement or evaluation activities must also be considered (Baker et al. 2004; CHSRF 2006; Rycroft-Malone et al. 2004). There are important limitations of a strictly rational approach to “evidence-based” decision-making in the complex world of organizational policy and planning decisions (Baker et al. 2004). Initiatives to increase use of evidence in decision-making have tended to focus on making information more available, accessible and attractive to decision-makers, and more recently, on increasing decision-maker capacity to use research. This approach reflects the assumption that the major barriers to decision-makers' use of evidence are data availability, accessibility and user capacity. However, as the organizational research described above suggests, the situation may be much more complex. While there has been some research on Canadian RHA decision-makers' and managers' use of evidence in decision-making (CHSRF 2005; Lavis et al. 2005; Mitton and Patten 2004), there has been limited exploration of how these managers view evidence or experience barriers to its use, and the extent to which this research has informed decision-makers' understanding of evidence use. Because the purpose of the From Evidence to Action proposal was to develop strategies for addressing barriers to evidence-informed decision-making faced by decision-makers in RHAs, it was critical to understand these barriers from their perspective.