Gestão da Saúde Baseada em Evidências Evidence-Based Management in Healthcare

1. Gestão da Saúde Baseada em Evidências Evidence-Based Management in Healthcare Bruce Fried, PhD Department of Health Policy & Administration University of North Carolina at Chapel Hill June 4, 2008

2. The Problem:Poor quality of management in health care

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

4. 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

5. 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

6. 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?

7. Managers face constraints in how they use information. Bounded Rationality

8. We are also constrained in our ability to process information.

9. A BRIEF EXPERIMENT On the following page you will see two upside-down smiling faces Raise your hand if you see two upside down smiling faces.

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

13. 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!

14. “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

15. The Challenger disaster Failure to seek out important information

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

17. Jésica Santillán before the operation

18. Jésica Santillán after the operation

19. The avoidable outcome: Failure to share information

20. When we talk about evidence-based management, this is not just a management exercise. Poor Management Can Kill

21. Evidence-Based management: Using what we know

22. 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.

23. Can we learn from the experience of evidence-based medicine? It is clear that evidence in medicine is under-used.

24. 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.

25. Awareness = AdoptionKnowledge = Practice

26. 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. 

27. Variations in spending for health care unrelated to health status Medicare Spending per Beneficiary, by Hospital Referral Region, 2005

29. 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.

30. The Pioneer Jack Wennberg, Dartmouth Medical School

31. 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

33. Overuse • Caesarean Section • Routine tonsillectomy • Surgical weight-loss • Back surgery

34. 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

35. Misuse • Off-label use of drugs • Antibiotics • Incorrect dosing for treatment of psychiatric disorders • Magnetic Resonance Imaging (MRI)

36. 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.

37. 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.

38. Two Types of Translational Research Translational research encourages partnerships between researchers, practitioners, and people skilled in translation.

39. Type 1 Translational Research Bedside Bench

40. Type 2 Translational Research Bedside Practice

41. Translational Research is NOT Unidirectional: There are FeedbackLoops Type 1 Type 2

42. There are problems implementing evidence-based medicine. But the problems are even more severe when we try to implement evidence-based management.

43. 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.

44. 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:

45. 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

46. Evidence-Based Management • Slower to take hold • Similar problems of overuse, underuse, and misuse

47. 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 How Decisions Are Made

48. But there is evidence that can be used to support management decision-making? • Core Business Processes and Transactions • Operational Management • Strategic Management

49. 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