EBM is now a recognised abbreviation for evidence based medicine, as the idea of encouraging its use has become increasingly fashionable. But the initials could also stand for evidence-based management.
Would this make sense? Can the same approach be applied to management as to medicine? If so, should it be?
Probably few people would argue that management should not be evidence-based, for fear of being seen to advocate management based on unreason; but probably many more would have doubts about whether it can be, and some would think that it should not be. Managers' opinions will depend on their view of management, and particularly of what is good management. Here there are similarities with some clinicians' response to evidence-based medicine, so it is useful to review briefly some of the main controversies that surround it: the validity and reliability of the evidence from studies.
There is great scope for arguing about how studies were done and about the nature of the sample; hence about how far the findings can be generalised, and how relevant they are for particular categories of patient who may not have been adequately represented in a trial;
the relative importance of evidence from studies of numerous patients compared with the clinician's judgement about an individual patient and the lessons they have drawn from experience.
These controversies help to explain why it is proving more difficult to get evidence-based medicine accepted and implemented than enthusiasts may have expected. They also suggest why evidence-based management would be difficult to implement.
The case for evidence-based management is much weaker than that for evidence-based medicine. Medicine is a profession for which there is a long training. Doctors are taught to look for evidence in their diagnosis and to learn the currently accepted methods of treatment, although what they learn will also be affected by the consultants for whom they work.
Medicine is both a science and an art, but management is more of an art than a science: someone can practise management without having been trained to be a manager and can even be a good manager without formal training, though the value of management education and training is becoming more widely accepted.
Research into management produces evidence that is less clear than is possible in medical research. This is true even for the most quantitative studies and even more true of the qualitative ones. Variables in management research cannot be controlled in the same way, and it is much harder than in medical research to predict the important variables. It is also harder to enlist co-operation in research because its potential value is less evident.
This does not mean that there is no case. To argue that would mean that no conclusions can be drawn from the evidence that is available: evidence of the relative effectiveness of different managements in how their trust, authority or company performs and in how a particular service operates; evidence from the evaluation of a particular change and from management research.
To these could be added historical evidence, but managers are rarely inclined to consider that; partly, at least, because they live in the present and seek credit for what they themselves are achieving - there is no management equivalent of the list of references required in medical and other research.
They could also argue - not always appropriately - that there is so much change that it no longer makes sense to try to learn from the past.
What is evidence-based management?
It is primarily an attitude of mind, which:
thinks in terms of evidence for decisions and about the nature of the evidence;
asks questions. What is happening? How is it happening?
Why? What are the consequences?
is aware of the potential limitations of the different answers;
is interested in research to try to find the answers or at least to reduce the ignorance.
This attitude of mind is necessary if a research culture is to exist. A simple test for its existence is whether a questioning approach is accepted and encouraged.
In a research culture managers encourage their staff to question what is being done, and group members encourage rather than sit on a member who questions the group's conclusions: some groups want to reach a conclusion too quickly and resent anyone who wants to consider other possibilities.
Factors encouraging and discouraging evidence-based management are summarised in the figure. The factors working against its adoption are:
working conditions: a heavy workload and tight deadlines allow managers less time to examine what they are doing;
poor work habits which prevent managers organising their time efficiently;
attitudes of the boss and of peers that emphasise the value of speedy decisions and getting on with the job;
personal beliefs: if, for example, individuals see management as mainly intuitive - though they may not use the word - they will rely more on their own judgement and experience than if they see it more as knowledge-based.
The factors that encourage it are:
a research culture;
personal beliefs: for example, that management is both an art and science; that there are lessons to be learned from the practice of others; that there is much to be learned about managing and that people should be seeking to improve the way they manage;
good work organisation that makes it easier to cope with a heavy workload;
sufficient self-discipline to be able to stand back from what one is doing and review it.
What can be done to promote evidence-based management? Most important is a common attitude in the organisation that encourages a research culture. Trying to develop that attitude where it does not exist is difficult and is made more so by heavy work pressures. It requires at least one senior manager to take a lead and to act as a role model.
Events can be organised to provide an opportunity for staff to take stock of how they are doing and to examine future plans.
Away days - quite popular in the NHS - can be one such event, so it is worth asking whether a recent away day fulfilled that purpose, and, if not, why not?
As harassed managers will be in no mood to practise evidence-based management, training in time management may be helpful, as may an examination of working practice.
Co-operating in research and encouraging staff to do research-based further education are other ways of stimulating an interest in evidence-based management.
Routines for considering future action, called 'mini-methods' by two Harvard University professors concerned with US government, can help to ensure that decisions take account of evidence.
1For example, they say: 'We urge that it become standard staff practice to start out by listing in three separate columns key elements of the immediate situation, namely those Known, Unclear and Presumed. That simple procedure puts attention on the situation itself instead of on the question 'what to do'.'
They suggest you ask yourself what fresh facts would cause you to change your presumption. They also point to the value of 'journalists' questions': when, what, where, who, how and why?
But such methods can and will only be used in a culture that recognises how they can save future problems from arising out of hasty and unconsidered actions.
Key Points
Evidence-based medicine can draw on more clear-cut research than that available for management. But it is still desirable to practise evidencebased management.
Managers should encourage a research culture and a questioning approach.
Developing a research culture requires at least one senior manager to act as a role model.
REFERENCE
1 Neustadt R, May R. Thinking in Time: the uses of history for decision makers. Colin Macmillan 1986.
Rosemary Stewart is director of the Oxford Health Care Management Institute, Templeton College, Oxford University.
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