REVIEWED BY CONNIE J. EVASHWICK, SC.D.
EVIDENCE-BASED MANAGEMENT IN HEALTHCARE
BY ANTHONY R. KOVNER Ph.D., DAVID J. FINE Ph.D., FACHE & RICHARD D'AQUILA, FACHE
Health Administration Press, 2009
300 pages, softbound, $79
For many who manage health care organizations, this text by three health care leaders will be a refreshing jolt, propelling them to focus less on today's political crisis and more on yesterday's solid data to revamp and improve tomorrow's operation of almost all management functions. Along with health care managers, the audiences the authors intend to reach include students of health care management, teachers, researchers and those who fund health services research. Two of the three editors are health care chief executives and the third sits on several hospital boards.
The book has four parts. Part I is an introduction to evidence-based management, including three examples of application, one by each of the three editors. Part II is the academic framing of the definition and theories. Part III is 10 case studies that demonstrate the variety of "evidence" available and how, in applying it, management practices and organizational performance improve. Part IV revisits "Lessons Learned."
The authors note that Thomas Rundall, Ph.D., and and other colleagues conducted a study of 32 senior health care executives to ask what basis they used for making management decisions. The results were alarming: "participants reported little use of research evidence in policymaking or managerial decision making." (p. 6) This leads to the uneasy conclusion that many management decisions in health care are made on some basis other than rationality and concrete data: gut feel, personal preferences, emotion or "we've always done it this way."
The authors acknowledge that "evidence" comes in a variety of forms, and past experience, experiences of others in similar situations, expert opinion and other qualitative methods can be applied in the absence of qualitative data. However, they urge, "What distinguishes evidence-based management from other approaches to decision making is the notion that whenever possible, health services managers should incorporate into their decision making evidence from well-conducted management research" (p. 56).
The authors propose four requirements for good evidence: It must be accurate, applicable, accessible and actionable. The latter is particularly important; no sense investing a lot of resources in collecting detailed information to sit on a shelf. The process of building and applying evidence is also important, with its six specific steps (p. xxiii): Frame the question (critical to the ultimate success or failure of the process); find the evidence; evaluate the evidence; assess its applicability and actionability; present the evidence to those who must act on it; apply the evidence to the decisions; evaluate the results. Beginning by asking the right question is critical to the ultimate success or failure of the evidence-based process.
Implementing an evidence-based approach to decision making may mean changing the entire organizational culture, and this may take time. The authors specify essential organizational parameters: leaders committed to an evidence-based approach; staff willing to learn the knowledge base and skills to apply evidence-based decision making; tools available for evidence creation and dissemination; recognition that internal structures and processes may need to change. More and better evidence is needed, and a respected national organization to champion and guide evidence-based management in health care is essential.
Despite its advocacy for use of sophisticated health services research and systematic rigor, the book takes a pragmatic approach. The case studies describe real-world situations and show how solutions to problems or improvements to outcomes were found based on using a scientific approach, applying new and existing data to find the best course of direction.
The case study format makes the book easy to read. Each case describes the problem at hand and demonstrates how the six steps of the evidence-based decision-making process were followed, as well as the outcome. The subjects cover an array of topics, from implementing pain management in a nursing facility to defining a better process for evaluating a hospital's chief executive. This range shows how broadly applicable the process can be.
If there is any weakness in the book, it is that relatively few examples of the detailed data were collected, including any secondary sources of information that might be available to others seeking to investigate the same problem. The cases describe more how the process was followed than what evidence was actually gathered, how rigorous it was and any methodological challenges that arose. This is somewhat inconsistent with the introduction to the book, which emphasizes the virtues of research sophistication and may reflect the different authorships in various parts. The framing chapters were written by academicians; the case studies primarily by practitioners or academician/practitioner co-authors. Nonetheless, giv-en the involvement of 20-some authors, the book does a fairly good job of maintaining a consistent voice across the chapters, though they vary in length and focus.
A couple of bonus features include a chapter entitled "Look it Up," which explains how to search the academic literature for the solid type of evidence most desired. An annotated bibliography at the end of the book provides a lengthy list of relevant articles and websites that offer further reading to those caught by the evidence-based bug.
As described in several of the case studies, becoming an evidence-based operation is an evolution that may start with one small project, and then grow over time to encompass the organization as a whole. Read the book — and let the journey begin!
CONNIE EVASHWICK is professor, School of Public Health, Saint Louis University.
BOOKS IN BRIEF
DIAGNOSIS CRITICAL: THE URGENT THREATS CONFRONTING CATHOLIC HEALTH CARE
Leonard J. Nelson III
350 pages, $29.95
Our Sunday Visitor, 2009
In his new book, Diagnosis Critical, Leonard J. Nelson III, professor of law at Samford University, warns that "the distinctive mission of the Catholic hospital is in grave danger of extinction." He reports that the identity of Catholic hospitals is being threatened by the convergence of powerful cultural, religious, economic and political forces, chief among them being "pro-choice" Catholic legislators, revisionist theologians, the ongoing leadership transitions to the laity and inconsistent application of church teaching and the Ethical and Religious Directives for Catholic Health Care Services (ERDs). Reviewing criteria for determining Catholic identity, Nelson dismisses mission, sponsorship and holistic care as being too vague or inadequately restrictive. Instead he argues that " — only ethics, and more particularly in the United States, compliance with the ERDs as interpreted and applied by the local bishop, provides any significant guarantee of continuing identity."
Nelson presents his evidence in six areas, ranging from moral foundations to social justice and health care reform, reviewing the considerable challenges faced by Catholic health care leaders. He highlights past controversies and speculates at length on what the nation's political leadership may do to further threaten the identity of Catholic hospitals. Notes documenting the text constitute a third of the volume.
Concluding that "the primary role of Catholic health care should be to provide support for the culture of life and to evangelize the secular culture," Nelson speculates that "perhaps it would be better to divert the resources of Catholic health care to alternative ministries." How this might be accomplished and the ethical issues involved in such a diversion of funds are not explored.
Having worked in secular and in Catholic hospitals, as a physician, ethicist and mission leader, I share Nelson's concern for the future of Catholic health care. However, while the author has documented a number of challenging issues, his methodology and analysis are at times distracting and even troubling. Moreover I find his criteria for determining Catholic identity to be unhelpfully narrow. Many of the founders of Catholic hospitals believed the provision of competent, compassionate care to the poor and marginalized to be an essential element of Catholic health care. It is certainly an element under every bit as much pressure today as those focused upon in this book. Those seeking workable solutions in their struggle to continue the healing ministry of Jesus will likely look elsewhere for inspiration.
— Msgr. Stephen C. Worsley, MD, S.T.L.
MSGR. WORSLEY is pastor, St. Stephen Church, Sanford, N.C.
HOPE IN AN AGE OF TERROR
Paul J. DaPonte
Orbis Books, 2009
"Any justification of the neighbor's pain must certainly be the source of immorality," writes Paul J. DaPonte, quoting Jewish philosopher Emmanuel Levinas in what he describes as "a theological reflection on evil and suffering, violence and revenge, identity and otherness." DaPonte's is one of numerous books since the Holocaust, and again since the terrorist attacks of Sept. 11, 2001, that explore such vexing theological questions as what was the role in all of this of the God we believe to be good? Why did God not come to the aid of victims who cried out for justice? How are believers in a good and just God to respond to massive horrors in which human beings are able, with the use of modern technology, to inflict once unimaginable sufferings on others, some even rationalizing their evildoing as part of God's design? Many philosophers and theologians have insisted that theodicies — efforts to justify a good God in light of human suffering — no longer apply.
DaPonte, assistant professor of religious studies at Stonehill College in Easton, Mass., divides his reflection into three parts: 9/10, metaphysical constructs about good and evil that preceded 9/11; 9/11 itself, meaning the day on which the age of terrorism fully dawned in the West; and 9/12, the era in which we now live. For a book that grapples with questions that get at the heart of our humanness, DaPonte's is reasonably accessible and provides both a historic overview of theodicies and a review of contemporary theological responses, philosophical, theological and practical, that might help us shape a better future. The task, DaPonte asserts, is to recognize our interconnectedness as humans and restore broken bonds by doing the work of repentance and forgiveness. As sources for this difficult work, he offers John D. Zizioulas, an Eastern Orthodox theologian and Metropolitan of Pergamon in Turkey, who "takes seriously the condition of enmity in a world where otherness and communion do not coexist," and Miroslav Volf, director of the Yale Center for Faith and Culture, who points to the crucified Christ as one who "judges both the initial wrongdoing of the perpetrators and the reactive wrongdoing of many victims" and calls on us to become enemies of our enmities. As for theodicy, DaPonte asserts that the question cannot be set aside. "The question of God and suffering never goes away," he writes, and "all theology must finally be answerable to it."
NOW THAT YOU'VE GONE HOME
Joyce Hutchison and Joyce Rupp
Ave Maria Press, 2009
With Rupp as coauthor, Hutchison, 67, shares her own journey with grief — the loss of her parents, her four siblings and her husband. These deeply personal stories are followed by stories of 15 others who relate their efforts to cope with the absence of a loved one.
Hutchison's descriptions of her anguish, especially after her husband died, are sure to be a source of comfort for those experiencing a similar loss. She writes about the empty house, the empty theater seat, the possessions to be let go of, the friends who avoid speaking about the lost loved one, the first holidays alone, the difficulty — even the impossibility at first — of moving on. Each story is followed by a meditation, a prayer and a simple task "for today," such as "I will embrace the goodness that each deceased person brought into my life and try to share this goodness with others." Hutchison offers this advice: "One of the best helps in mourning the death of a loved one is to stay with my grief and to give myself permission to feel those emotions as much as I can. — As I allow my grief to come forth, I tell myself, 'My heart is broken today, but there will come a time when this heartache no longer sweeps over me and consumes me.'" She tries to remember too, that her pain is a product of her vast love.
Stories by others describe the loss of children, parents, grandparents, a husband who took his own life. A bereaved reader reflecting on these stories is sure to feel less alone.
Material drawn from Now That You've Gone Home is woven through CHA's Advent podcasts, available at www.chausa.org.
— Pamela Schaeffer
Copyright © 2010 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.