EVIDENCE-BASED MANAGEMENT AND ITS INFLUENCE ON THE PRACTICES OF

SENIOR LEADERS OF HOSPITALS IN THE DENVER METROPOLITAN AREA

A Dissertation Presented in Partial Fulfillment of the

Requirements for the Degree of
Doctor of Management

By

Charment Oscar Moussata

Colorado Technical University

February 9, 2017




ProQuest Number: 10637085




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 Committee

Daphne DePorres, EdD, Chair

Peter Moskowitz, Ph.D., Committee Member

Ronald Bucci, Ph.D., Committee Member

February 9, 2017
Date Approved
© Charment Moussata, 2017

i
 Abstract

Evidence-based management (EBMgt) and evidence-based medicine (EBM) are two key

constructs that senior leaders of hospitals and health system may leverage to foster a culture of

evidence-based decision making in their organizations. A great need exists for understanding

how the two principles, EBMgt (context for providing care) and EBM (content for providing

care), interact to provide high-quality care and effective leadership that is needed to improve the

performance of healthcare organizations of the 21st-century. Health decision-makers such as

senior administrators and medical staff leaders are essential components of healthcare

organizations to develop a culture of evidence-based decision making. However, few studies

address the linking of EBMgt and EBM, including its impact on the senior leaders and

organization management practices. The current exploratory qualitative study explored the lived

experiences with EBMgt of senior executive leaders of hospitals and health systems in the

Denver Metropolitan that practice EBM. The findings reveal that EBMgt practices are still yet to

be implemented systematically in healthcare organizations in the area. However, hospital

decision-makers believe that EBMgt-EBM integration might have a positive impact in how

hospitals can provide reliable, high-quality, evidence-based health care to their communities.

Hence, to cope with the ever-increasing pace of business change in the 21st-century, hospital

leaders should consider the implications that the integration of EBMgt-EBM might have on

evidence-based strategic management and performance of their institutions.

ii
 Dedication

To my wife, Monique Sendze-Moussata. You have been supportive throughout every step of my

doctoral journey. You have inspired me to become the best version of myself.

To my children, Chardel Moussata, Liysi Moussata, and Chlorycia Moussata. You have been the
source of my strength and inspiration. Thanks for your support.

iii
 Acknowledgements

I would like to thank Dr. Daphne DePorres, the Committee Chair, for her guidance and

patience. You have been a great mentor to me, and I could not have completed this journey

without you.

I would sincerely like to acknowledge Dr. Peter Moskowitz and Dr. Ronald Bucci not

only for serving in my committee but also for teaching me Economics & Financing of

Healthcare Organizations and Continuous Improvement for Systems in Healthcare, respectively.

Furthermore, my sincere gratitude goes to the faculty and my peers at the Colorado

Technical University who supported me through my doctoral journey and contributed to my

scholarly success.

iv
 Table of Contents

Abstract ........................................................................................................................... ii

Dedication ...................................................................................................................... iii

Acknowledgements ........................................................................................................ iv

Table of Contents ............................................................................................................ v

List of Tables ................................................................................................................. ix

List of Figures ................................................................................................................. x

CHAPTER ONE ............................................................................................................. 1

Topic Overview/Background ...................................................................................... 3

Problem Opportunity Statement ................................................................................. 5

Purpose Statement ....................................................................................................... 6

Research Question ...................................................................................................... 7

Theoretical Perspectives/Conceptual Framework....................................................... 7

Assumptions/Biases .................................................................................................... 8

Significance of the Study ............................................................................................ 9

Delimitations ............................................................................................................... 9

Limitations ................................................................................................................ 10

Definition of Terms................................................................................................... 10

General Overview of the Research Design ............................................................... 11

Summary of Chapter One ......................................................................................... 12

v
 Organization of Dissertation ..................................................................................... 12

CHAPTER TWO .......................................................................................................... 14

Review and Discussion of the Literature .................................................................. 14

Evidence-Based Medicine (EBM) and Evidence-Based Management (EBMgt) ..... 15

Overview of Evidence-Based Management Movement ........................................... 17

EBMgt Not a Common Business Practice ................................................................ 21

Factors Impeding EBMgt and EBM-EBM Integration ............................................. 22

Evidence-Based Management Processes .................................................................. 24

Integration of EBM and EBMgt ............................................................................... 25

EBMgt and Organizational Contexts ........................................................................ 26

Culture of Evidence-Based Decision Making........................................................... 26

Implications for EBMgt and EBM Integration ......................................................... 28

Integrated Conceptual Model for Developing a Culture of EBDM .......................... 30

Conceptual Framework ............................................................................................. 32

Summary of Literature Review ................................................................................. 37

CHAPTER THREE ...................................................................................................... 39

Research Traditions .................................................................................................. 40

Research Question .................................................................................................... 41

Research Design........................................................................................................ 41

Population and Sample ............................................................................................. 42

vi
 Sampling Procedure .................................................................................................. 45

Instrumentation ......................................................................................................... 46

Credibility and Trustworthiness ................................................................................ 49

Reliability.................................................................................................................. 50

Data Collection ......................................................................................................... 51

Data Analysis ............................................................................................................ 52

Ethical Considerations .............................................................................................. 53

Summary of Chapter Three ....................................................................................... 54

CHAPTER FOUR ......................................................................................................... 56

Pilot Study and Research Setting .............................................................................. 56

Participant Demographics ......................................................................................... 57

Presentation of the Data ............................................................................................ 61

Presentation and Discussion of Findings .................................................................. 81

Emerging Themes ..................................................................................................... 82

Summary of Chapter Four ........................................................................................ 93

CHAPTER FIVE .......................................................................................................... 95

Findings and Conclusions ......................................................................................... 96

Limitations of the Study.......................................................................................... 102

Implications for Practice ......................................................................................... 104

Recommendations for Future Research .................................................................. 108

vii
 Reflections .............................................................................................................. 109

Conclusion .............................................................................................................. 110

References ................................................................................................................... 111

Appendices .................................................................................................................. 128

Appendix A: Invitation to Participate in a Dissertation Research Study ................ 128

Appendix B: Study Informed Consent .................................................................... 130

Appendix C: Interview Protocol Guide .................................................................. 132

Appendix D: Denver Metropolitan Area Map ........................................................ 135

Appendix E: Demographic Characteristics of Participants .................................... 136

Appendix F: Listing of Coding Reports.................................................................. 138

viii
 List of Tables

Table 1. Distribution of Participants by Gender and Job Titles or Positions 59

Table 2. Participants’ Management and Leadership Experiences 60

Table 3. Demographic Profile of Participants’ Education 60

Table 4. Concept Understanding 63

Table 5. Typical Example Areas of Use of EBMgt 64

Table 6. Extent of EBMgt Use 68

Table 7. Participants’ Perception of EBMgt-EBM Role 71

Table 8. Influence of EBMgt on Senior Leaders 73

Table 9. Influence on CEOs and Senior Leaders 75

Table 10. Most Important Factors 77

Table 11. Barriers to EBMgt and EBMgt-EBM Integration 79

Table 12. Champions of EBMgt-EBM Integration 80

Table 13. Study’s Major Themes 83

Table 14. Major Themes and Minor Themes 90

ix
 List of Figures

Figure 1. Conceptual framework 33

x
 CHAPTER ONE

With the ever-changing landscape of medical science and technology, including the

increased demand for most effective treatments and their associated high costs, health care

organizations are facing immense challenges in delivering the best care to the populations they

serve (Bell, 2011). Despite the constant pressure of balancing transitory financial, regulatory, and

technological environments, senior health executive leaders must develop comprehensive

strategic visions to ensure the sustainability and growth of their institutions (Yarbrough Landry,

Stowe, & Haefner, 2012). These decision-makers also need to ensure the best use of their

institutions’ limited resources (Akyürek, Sawalha, & Ide, 2015). To provide high-quality and

cost-effective care in the 21st century’s competitive and complex healthcare arena (Hanson et al.

2011), executives of hospitals and health systems have the immense responsibility to use

evidence-informed decision-making processes to make clinical and non-clinical management

decisions.

With increasing hospital stakeholder demands for performance accountability, Rundall et

al. (2007) noted that evidence-informed management would help senior healthcare managers use

the best available scientific evidence to inform organizational strategic decisions. It will also help

health executives transform hospital structures and culture to promote an efficient uptake and use

of research evidence in their organizational decision-making processes. To this end, hospitals

must have in place a culture that fosters using evidence-based decision-making at all

management and leadership levels.

Bell (2011) maintained that it is imperative for hospital executives, administrators, and

senior medical managers to understand that integrating evidence-based medicine (EBM) and

evidence-based management (EBMgt) in healthcare settings is now more critical than ever for

1
developing such a culture. Understanding how these two evidence-based principles, EBM and

EBMgt, interact and integrate is paramount to providing “effective healthcare leadership” (Bell,

2011, p. 24). To ensure hospitals achieve excellent performance as health systems, their chief

executive officers (CEOs) and other senior administrators have the responsibility to promote

integrating medical and management sciences (Bell, 2011). With such integration, leadership is

sure to develop “a shared culture between medicine and management” (Shortell, 2006, p. 26) that

can contribute to healthcare quality and overall hospital performance in the Unites States.

The literature shows that a correlation exists between hospital quality management

practices and overall performance (Carter, Lonial, & Raju, 2010). Carter et al. maintained that

“both the quality practices related to clinical care results and the overall system or quality

context are needed to ensure hospital performance” (Carter et al., 2010, p. 8). Similarly, other

health management scholars, such as Shortell et al. (2007), noted that two components, EBM and

EBMgt, are key elements to improving hospital medical care and performance (Shortell,

Rundall, & Hsu, 2007). By incorporating EBM and EBMgt practices, as well as assessment tools

such as the Malcolm Baldrige model, hospital chief administrators can improve and build

performance alignment across their organizations (AHA, 2014).

Despite worldwide acceptance of EBM (Rycroft-Malone, 2008; Squires et al., 2011) and

growing interest in EBMgt research (Guo, 2015), few American healthcare organizations have

successfully implemented EBMgt (Arndt & Bigelow, 2009; Kovner & Rundall, 2006; Shortell,

2006). Although researchers have expressed several reasons for slow EBMgt adoption and

implementation in healthcare organizations (Kovner, Fine, & D’Aquila, 2009), Bosman (2015)

agreed with the perspective that senior management of hospitals and health systems use EBMgt

principles and practices without realizing it. This study assumed that senior hospital executives

2
and managers already perform some of the six key steps of the EBMgt approach contained in the

Informed Decisions Toolbox proposed by Rundall et al. (2007). However, health scholars know

little about how executive management team leaders integrate evidence from both EBMgt and

EBM to make evidence-based strategic decisions in healthcare organizations such as hospitals.

Given how the Affordable Care Act (ACA) has changed the complex functioning of the

American healthcare system (Dalton, Sullivan, Yeatman, & Fenstermacher, 2010), using EBMgt

to improve hospitals’ managerial decision-making and performance appears to be indispensable

(Smith, 2009).

Topic Overview/Background

The ACA has opened the door to new opportunities for healthcare organizations that

provide advanced medical services with real, far-reaching impact on people’s lives (O’Connor et

al., 2013). For healthcare to be successful in providing high-quality care that relies on EBM, it is

essential that executive leaders of these institutions link EBM and EBMgt for both concepts to

become standard practice. For this linkage to happen, senior hospital leaders have to develop a

culture of evidence-based decision making that is critical to supporting organizational strategic

decisions.

Currently, however, little research has been conducted to examine how senior hospital

leaders in the United States use evidence from both EBM and EBMgt to make evidence-based

strategic decisions in support of developing such a culture that can improve organizational

performance. Although EBMgt, or evidence-informed management, is about managers making

decisions by using the best available evidence (Rundall et al. 2007), healthcare executives are

responsible for implementing evidence-based practices in their organizations successfully.

Hospital administrators have the responsibility and the authority of transforming their

3
organization’s structures and culture in support of encouraging research evidence that promotes

efficient management decisions (Rundall et al., 2007). Consequently, a hospital board and

executive leadership have an essential role to ensure that their organization’s managerial culture

supports of EBMgt (Walshe & Rundall, 2001). Toward this end, leadership must become

familiar with EBMgt principles to understand where a need exists to incorporate EBMgt

practices and processes that deliver the best patient healthcare (Potworowski & Green, 2012).

Although Rundall and Kovner (2006) cautioned that EBMgt “does not prescribe the kind of

evidence, how to obtain it, or what decisions should be made,” Rynes, Rousseau, and Barends

(2015) maintained that EBMgt constitutes a professional management practice.

To guide the study operationally, the term EBMgt equates to “the complementary use of

scientific evidence and local business evidence” that hospital executives and senior managers

utilize to manage hospitals effectively (Rousseau, Manning, & Denyer, 2008, p. 10). Equipped

with such a broad operational definition and the extent of the current literature on EBMgt

(Hewison, 2003; Greenhalgh et al., 2004; Walsh & Rundall, 2001), Reay et al. (2009) indicated

that ample evidence exists about the use of EBMgt approaches. EBMgt, therefore, is a thinking

approach that helps hospital management and leadership address organizational problems and

decisions.

From the previously mentioned operational definition, one understands that the use of

EBMgt can help hospitals’ professional and non-professional medical members collaborate and

engage in change management practices that can improve overall institutional performance. Such

collaboration is essential to help executives use EBMgt approaches to not only tackle

organization management problems but also to provide effective leadership using EBDM to

create a sustainable and quality-driven health system (Bell, 2011, p. 36). As a result, hospital

4
leaders need to possess the skills, knowledge, and understanding of implementing EBMgt to

ensure their institutions incorporate EBMgt at all management and leadership levels to improve

performance.

Problem Opportunity Statement

Despite the advance in medicine and technology, still, more than 45% of the U.S.

population does not receive advanced medical interventions that EBM requires (McGlynn et al.,

2003; Shortell, Rundall, & Hsu, 2007). To ensure American patients receive the best possible

healthcare, healthcare providers may benefit by incorporating both EBM and EBMgt practices

into their organizations (Shortell et al., 2007). Although clinical professionals (doctors and

nurses) are committed to embracing EBM in the last two decades, healthcare executive leaders

have been slow and reluctant in incorporating EBMgt approaches into their decision-making

processes (Shortell et al., 2007; Heiwe et al., 2011). Bridging this gap is critical to developing an

evidence-based decision making (EBDM) culture and enhancing the performance of healthcare

organizations.

Currently, no evidence exists about how senior hospital executives and managers

implement EBMgt and its linking with EBM in their health firms. Also, scholars know less about

the types of evidence (scientific, organizational, and experiential, including organizational and

stakeholder values) management practitioners use to make operational and strategic management

decisions (Rundall & Otte-Trojel, 2016. Arndt and Bigelow (2007) noted that a lack of empirical

management research evidence exists to demonstrate the influence of EBMgt practices on the

performance of healthcare settings such as hospitals. Therefore, this research inquiry aimed to

contribute to this issue and to open the door to new research opportunities. It also sought to

extend the initial work of Shortell et al. (2007) by interviewing members of senior hospital

5
executive management in the Denver Metropolitan area to understand how they leverage

evidence from EBMgt and EBM in support of making strategic decisions. This study offers an

excellent opportunity to learn about various management issues that healthcare organizations

face to achieve the integration of EBMgt and EBM.

Purpose Statement

The goal of this investigation is to learn and understand how executive leaders and

managers of hospitals and health systems in the Denver Metropolitan are combining (or not) both

EBMgt and EBM to improve quality and performance of their institutions. Thus, this study

explored the adoption and implementation of (a) EBMgt, (b) its integration with EBM, and (c)

the perceived influence of EBMgt-EBM integration on hospital performance of these

organizations. This study also explored what senior hospital leaders viewed as the critical

contextual factors that impede or facilitate the integration of EBMgt and EBM in hospitals that

simultaneously implement safety and quality improvement initiatives. Hung et al. (2015)

indicated that with the culture of EBMgt, healthcare organizations would be successful in

implementing EBDM as a novel paradigm in the medical field.

With this study, this researcher hopes to unravel the contributions (roles) and benefits of

EBMgt in U.S. hospitals in Colorado as perceived by their senior management and leadership.

The study might shed significant insights into the development of a culture of EBDM in

hospitals that integrate EBM and EBMgt. Such investigation can help healthcare executives

understand the relationship between EBMgt and health organizational performance to show how

EBMgt practices can benefit hospitals as a whole healthcare system. Although considerable

barriers exist that influence EBM and EBMgt practice in hospitals, the linkage between these

two concepts might help hospitals accelerate adopting EBMgt practices and create a significant

6
competitive edge for these healthcare institutions. This integration may increase the population

of patients who receive 21st-century EBM interventions. Given the challenges that healthcare

organizations face, especially hospitals, are facing in this century, Marr (2010) remarked that

“the time has arrived for a systematic, evidence-based approach to making decisions” (p. 12).

Although the benefits of EBMgt incorporation for healthcare organizations appear to be

“incalculable,” penalties for hospitals that will not do the same are significant (Marr, 2010).

Research Question

The following research question guided this study: What can be learned from senior

hospital executives and health systems in the Denver metropolitan area about how to

systematically implement EBM-EBMgt? Thus, this study addressed EBMgt, EBMgt-EBM

integration and the assumption that this integration is paramount to executive decision-makers to

address hospital operational management and strategic management issues.

Theoretical Perspectives/Conceptual Framework

A conceptual framework derived from an extensive literature review of EBMgt and EBM

provided direction for the overall research question and the methodology of this academic

research endeavor. The framework considers EBM (content of providing care) and EBMgt

(context of providing care) as key components of evidence-based practices for hospitals to

deliver high-quality care (Shortell et al., 2007). In this framework, content (the “what”), context

(the “why” and “when,”), including the process (the “how” and “by whom”) are essential to

healthcare leadership (Anderson et al. 2011, p.121). Senior hospital executive management

(leadership) plays a significant role in implementing EBMgt and EBM practices. As such,

integrating these two evidence-based concepts will only help benefit hospital strategic decision-

making.

7
 EBMgt requires a transformation not only of the organizational strategies, structures, and

management practices (environment) but also of perceptions, beliefs, including practices of

executive leaders and other professionals. Thus, integrating EBMgt-EBM also requires hospital

executive officials to engage in transformational leadership and EBMgt practices (Page, 2004) to

support implementing these two principles throughout a healthcare setting. By so doing and

using EBMgt approaches such as the Balanced Scorecard (Kaplan & Norton, 1996), hospital

management and leadership teams can leverage the power of communicating and collaborating

to share relevant information (evidence) needed to make evidence-based strategic decisions.

Assumptions/Biases

According to Fortus (2009), researchers’ assumptions constitute one of the most

important steps of the process to solving many real-world problems. Fortus (2009) described

assumptions as a set of propositions used to establish the foundation of a problem-solving

process. Therefore, these propositions, which may include facts or principles that research has

not verified yet, can allow researchers to interpret the world according to their unique

worldviews resulting in confirmatory bias (Bowden, 2014).

The research investigator’s professional experiences working in the pharmaceutical

industry for the past 15 years contributed to perceptions of healthcare organization executives’

ability to make strategic management decisions using research evidence. As a leader in the

research and development environment, he has participated in cross-functional departmental

strategic decision-making focused on critical organizational areas to ensure growth,

sustainability, and expansion of the company’s product pipeline. As such, this has contributed to

personal bias about understanding that hospital executives make strategic decisions primarily

driven by data instead of integrating EBMgt and EBM evidence. With this perspective in mind,

8
the researcher attempted to control biases to ensure they did not influence the interpretation of

the participants’ experiences. For example, as a scientist, one may assume that EBMgt decisions

are always data-driven and that intuitions do not matter in a decision-making process. Whiting

(2005) reported that healthcare executives make intuitive decisions and believe that they do not

need to support them with data. This investigator took into account his biases and made a

conscientious effort to be aware of them throughout this research inquiry.

Significance of the Study

The current doctoral research might contribute to understanding the factors and benefits

of implementing EBMgt, including linking EBMgt-EBM, to enhance the quality of healthcare

services American hospitals provide to their communities. The study may also help to bridge the

gap of knowledge that exists in the literature concerning integrating EBMgt and EBM. The

findings of this research inquiry are expected to provide insights to better understand the

influence of evidence-based informed decisions on the quality of care and hospital performance

as perceived by healthcare executives. It may also contribute to the overall national effort to

improve quality and reduce healthcare costs in the U.S. healthcare system.

Delimitations

The scope of this research project focused on understanding the current extent of EBMgt

use, including its integration with EBM, by senior executive hospital leaders of the Denver

Metropolitan area who practice EBM. This population included health system leaders who were

fellows and members of the American College of Healthcare Executives (ACHE, 2016) and

whose hospitals are members of the American Hospital Association. These management

executives or leaders comprised chief executive officers (CEOs) and other top administrators

from the clinical and non-clinical management teams. In addition to their administrative title

9
positions, these healthcare leaders must possess at least two years of hospital management

experience to be included in the study sample (Guo, 2015). Toward this end, the investigator

included and interviewed participants holding top executive leadership positions.

Limitations

Because this research project was an exploratory investigation, it was limited due to its

small participant and health system sample size. Also, the use of exploratory-based interview

questions constituted another limitation because of the investigator’s bias. Nonetheless, the

researcher conducted interviews in a manner that prevented influencing participant responses.

This study also presented limitations with interviews requiring hospital participants to self-assess

and report EBMgt practices concerning their organizations instead of using experimental

research methods to collect data (Polit & Beck, 2008).

Definition of Terms

The following identifies definitions of terms relevant in the context of this study:

 Evidence—Evidence is credible and tested knowledge from diverse sources; it

includes research knowledge, practical knowledge, including local data, and

personal experience to name just a few (Stetler, Ritchie, Rycroft-Malone, Schultz,

& Charns, 2009).

 Evidence-based medicine (EBM)—Sackett et al. (1996) view EBM as the best

approach for using current evidence conscientiously, explicitly, and judiciously to

make effective decisions about patients’ healthcare. Thus, practicing EBM

consists of making sure that medical practitioners integrate their past experiences

with the most recent and best available external clinical evidence from systematic

research (Sackett et al., 1996). With this practice, clinicians also include their

10
 expertise, patient values, and preferences as evidence to derive a best rational

medical intervention for the patient (Straus & Sackett, 1998).

 Evidence-based practice (EBP)—Evidence-based practice is a paradigm shift for

making decisions that integrate the best available research evidence with

practitioners’ expertise and clients’ (or customers) preference that can guide

practice to more desirable results (Rousseau, 2006). It derives from the best

available evidence to achieve positive organization outcomes (Stetler et al., 2009).

 Evidence-based management (EBMgt)—Evidence-based management is the

systematic, evidence-informed practice of management that incorporates scientific

knowledge in the content and process of making decisions (Rousseau, 2012, p. 3).

It is an emerging movement or field of study in management (Reay, Berta, &

Kohn, 2009, Pfeffer, 2010; Rousseau, 2012) that aims at bridging the gap that

exists between management research findings and management practice (Bennis

& O’Toole, 2005).

General Overview of the Research Design

A paucity of empirical studies exists on the subject of integrating EBMgt and EBM in

healthcare organizations, in particular hospitals. The existing literature revealed just one

publication, the work of Shortell et al. (2007) that addressed linking EBMgt and EBM for health

providers in support of better patient care. With a recent increase in calls to action for evidence-

based decision making in healthcare organizations (Kohn, 2013), it is time for scholars and

practitioners to understand how EBMgt and EBM linkages may benefit senior hospital

executives in developing evidence-based strategic organizational decisions. As such, an

exploratory qualitative research design was employed to explore broader issues related to EBMgt

11
and EBM integration that hospitals face from a small number of participants through using in-

depth interviews (Perry et al., 1999). Toward this end, this exploratory investigation sought to

extend the initial effort of the study mentioned herein to open new research opportunities (Beall,

2002).

Summary of Chapter One

With the endless proliferation of new clinical research findings as well as medical and

technological advancements, healthcare senior managers and administrative officers must make

evidence-informed decisions to help hospitals adapt to the 21st-century environment. By so

doing, these executives will create a competitive edge for their institutions by providing clear

choices to patients in this consumer-driven business climate. To sustain this competitive

advantage, senior healthcare executives of organizations such as hospitals need to realize that

“knowledge and understanding of both evidence-based medicine and evidence-based

management are useful for improving the quality of care and leading change in the hospital”

(Bell, 2011). Implementing these two practices will better position hospitals to respond to the

needs of well-informed patients and the demands of the highly competitive and ever-changing

healthcare industry. Toward this end, EBMgt, which is the use of best scientific evidence and

relevant practice, offers opportunities to improve managerial practices and to promote EBM

(Pepitone, 2009). Hence, a great need exists for EBMgt research to help hospitals in the United

States become EBMgt-institutions.

Organization of Dissertation

This study includes five chapters. The first chapter addressed the following research

question: What can be learned from senior hospital executives and health systems in the Denver

metropolitan area about how to systematically implement EBM-EBMgt? It highlighted the

12
importance of EBMgt-EBM as a research issue and the rationale for this study. Chapter Two

reviews the literature related to EBMgt to shed light on the significance of integrating both

EBMgt and EBM concepts in support of developing a culture of evidence-based decision making

in hospitals. Chapter Three provides an explanation of the research design and the methodology

applied in this research endeavor. It offers the rationale for selecting an exploratory qualitative

study and the process of conducting a pilot study, recruiting participants, and collecting and

analyzing data. Chapter Four outlines the findings of the dissertation study whereas Chapter

Five provides an interpretation of the findings, study implications, as well as recommendations

for future research.

13
 CHAPTER TWO

This chapter outlines a review of the relevant literature concerning the emergence of

EBMgt, its current practice in hospitals, its barriers, including facilitating factors, and a

framework to analyze and optimize its use by senior hospital managers in strategic decision-

making. Chapter Two also explores relevant literature that can shed light on the significance of

integrating EBM and EBMgt concepts in support of developing a culture of evidence-based

decision making in healthcare settings. It also highlights important literature (i.e., seminal,

contextual, and current) that was essential not only to situating the research topic of EBMgt,

including EBMgt-EBM integration, in this study but also to understanding the conceptual

framework and the overall research question of this endeavor.

An overview of the existing body of knowledge made a case for examining if healthcare

managers and executives support and use EBM and EBMgt evidence in making strategic

decisions. By so doing, hospital leaders can help create a culture of evidence-based practice that

will make EBMgt and EBM become two coexisting realities in the healthcare setting (Stetler,

Ritchie, Rycroft-Malone, & Charns, 2014) to enhance the quality of care and institutional

performance. Such integration can promote the use of evidence-based decision-making processes

in hospitals.

Review and Discussion of the Literature

Chapter Two first reviews the concepts of EBM and EBMgt, and their roles as constructs

in building a culture of evidence-based decision making in healthcare organizations such as

hospitals. In the context of this study, as Mullen and Streiner (2006) explained, evidence-based

principles encompasses not only clinical practices (EBM) but also policy and management

practices (EBMgt). Although Chapter Two discusses the link between EBMgt and its integration

14
with EBM, evidence-based strategic decision-making, and organization performance, it also

reviews the role of organizational contextual factors concerning EBMgt and EBM integration.

Finally, this chapter presents an integrated conceptual model that may help hospitals integrate

EBMgt and EBM.

Evidence-Based Medicine (EBM) and Evidence-Based Management (EBMgt)

With EBMgt still in its infancy stage, a myriad of definitions associated with the term

exist. Hawkins (2013) stated that applying EBM principles within the larger scope of healthcare

practice constitutes evidence-based practices. Locket (1997, p. 11) indicated that these practices

initially represented “the process of systematically finding, appraising, and using

contemporaneous research findings as a basis for clinical decisions.” Researchers such as

Hawkins (2013) proposed extending the use of EBM principles into other areas of healthcare

organizations that are beyond clinical operations. Axelsson (1998) was the first scholar to

suggest that healthcare managers needed to find ways to include management research findings

into their managerial practices. He referred to this practice as “evidence-based management,” to

encourage using research evidence that can improve management practices. Kovner et al. (2009)

equated EBMgt to “the systematic application of the best available evidence to the evaluation of

managerial strategies for improving the performance of health services originations” (p. 56).

According to Briner et al. (2009), EBMgt is a management approach that requires making

evidence-based decisions from four information sources in a deliberate, conscientious, explicit,

and judicious manner. These sources are (1) practitioner expertise and judgment, (2) evidence

from the hospital’s internal or local research, (3) a critical evaluation of the best available

academic research data, and (4) perspectives of the impacted stakeholders. However, Rousseau

(2012), one of the founders of the EBMgt movement, defined EBMgt as “the systematic,

15
evidence-informed practice of management, incorporating scientific knowledge in the content

and process of making decisions” (p.3).

Since EBMgt is still in its infancy stage as indicated earlier, variable definitions

associated with the term exist. Therefore, it is important to note that as the definition of EBMgt

continues to evolve, it is clearly differentiating itself from the concept of EBM. Although

sufficient medical literature exists to support the maturity of empirical research in EBM (Kohn,

2013), management literature on EBMgt is still emerging and has focused mainly on a call to

action for healthcare organizations to embrace EBMgt. With EBM, many empirical models exist

to facilitate hospital leaders and managers to implement evidence-based practices (Gawlinski &

Rutledge, 2008). Unlike EBM, most studies on EBMgt are prescriptive and based on

observational studies that address barriers to EBMgt implementation (Grol & Wensing, 2004).

For this reason, many scholars consider EBM to be a first paradigm shift in support of applying

evidence that can improve the quality of medical decisions resulting in reduced variation of

health services and better clinical outcomes (Kovner et al., 2000; Walshe & Rundall, 2001).

Shortell et al. (2007) remarked that as two unique constructs, EBM and EBMgt are

essential key components critical to enhancing the quality of medical care and hospital

performance. However, these two constructs are different. EBM, which relates to clinical

hospital practices leading to better care, constitutes the “content of providing care” and the

knowledge of how to make it routine hospital practice (Shortell, 2006). On the contrary, EBMgt

forms the “context of providing care.” It relates to hospitals’ organizational strategies, structures,

and change management practices that healthcare organizations use to provide more advanced

evidence-based healthcare. According to Rundall et al. (2007), although EBM (content) enhances

health provider quality of care, EBMgt (context) improves the quality of decisions concerning

16
hospital operational management and performance. Thus, both of these evidence-based

principles are relevant to health decision-makers in providing essential information (or evidence)

needed to improve hospital medical and management decision-making processes. However,

successful EBMgt and EBM implementation in healthcare settings depend on critical contextual

factors such as institutional leadership and culture; this includes the quality of resulting evidence

EBMgt-EBM integration provides to executive management (Damschroder et al., 2009).

Overview of Evidence-Based Management Movement

Based on the ongoing debate about the impact of EBMgt, Guo (2015) proposed

categorizing EBMgt movements into three distinct historical phases. EBMgt is an emerging

movement or field of study in management (Reay, Berta, & Kohn, 2009, Pfeffer, 2010;

Rousseau, 2012). This movement has resulted in responses to the overwhelming concerns of

scholars and practitioners about the gap that exists between management research findings and

management practice (Bennis & O’Toole, 2005). EBMgt aims to bridge this research–practice

gap by allowing executives and managers in organizations to include the best available scientific

evidence in their management decision-making process (Rousseau, 2006).

The Emergence Phase of EBMgt: 1998-2006

At the emergence stage, scholars such as Stewart (1998); Axelsson (1998); Kovner,

Elton, and Billings (2000); and Walshe and Rundall (2001) began speculating about introducing

EBMgt principles into healthcare organizational practices. Although still in its infancy, the

EBMgt movement began to distinguish itself from EBM. As a result, this phase was

characterized by a debate between scholars to separate EBMgt from EBM in which healthcare

researchers began discussing the application of EBM principles into management practices.

17
The Acceptance Phase of EBMgt: 2006-2013

Some scholars considered the EBMgt acceptance phase as a period when more

researchers and practitioners started recognizing the need and significance to embrace this

concept as a means to incorporate the best available research evidence into management

decision-making in support of improving managerial practices (Guo, 2015). This phase saw an

increase in the number of scholarly publications (articles and books) addressing EBMgt. For

example, Kovner and Rundall (2006) wrote the first book presenting the potential benefits that

EBMgt could provide patients and healthcare organizations. Thus, management researchers and

scholars, including those outside of the health system such as Pfeffer and Sutton (2006),

Rousseau (2006), including Rousseau, Manning, and Denyer (2008), began to emerge as the

proponents of EBMgt practice. Over time, several other scholars added new perspectives to the

debate. During this stage of the movement, the literature became divided into two main groups:

(a) the promoters and (b) the critics.

Those who advocated for EBMgt, i.e., the proponents, argued that “many managers do

not use the best scientifically proven approaches to managing their companies” (Tort-Martorell,

Grima, & Marcoand, 2011). On the proponent side of the debate, the focus was that an

organization needs to incorporate EBMgt practices, i.e., any idea, structure and methodology that

has proven to be effective scientifically. However, not all proponents rejected all ideas that

contradicted EBMgt thinking. Within this category, a sub-group of investigators and

practitioners believed that executives and managers of organizations have been practicing

EBMgt for a long time (Speicher-Bocija & Adams, 2012). By the nature of their work,

managers, often, utilize their experiences, personal judgment, recommendations from colleagues

as evidence in supporting their managerial decisions (Reay, Berta, & Kohn, 2009). Finally, a

18
second sub-group contended that because management is not a profession, managers cannot

distinguish “the best management practices” as Rousseau and McCarthy (2007), including

Cascio (2007), suggested. The proponents of this sub-group of EBMgt, as Hofmann (2010)

remarked, maintain that managers of healthcare organizations have to recognize the ethical

issues that they create by not accelerating and creating conditions for an all over (even) adoption

of EBMgt in their organizations.

Few scholars lead the critics or the opponent group of the EBMgt movement. For

example, Kieser and Leiner (2009) have used a system theory perspective to show that two social

systems such as (a) the academic community (or science) and (b) the social system made of

business organizations (management practitioners) cannot communicate collaboratively to bridge

the research-practice gap. Thus, Kieser and Leiner (2009) argued that there is no justification to

engage in EBMgt because it is not practical to close the gap between these two systems. Within

this group, researchers believe that because EBM and EBMgt have different contexts, it is

impossible to apply the principles of EBM into EBMgt.

Despite the potential benefits the proponent side has advanced concerning adopting

EBMgt into healthcare management, Reay et al. (2009) indicated that no substantial empirical

studies exist showing “that employing EBMgt will improve organizational performance.” Based

on the review of the literature explored for this study, the researcher of this study agreed with

Reay and colleagues (2009) that most of the previous work on EBMgt only encourage adoption

of its practice “based on opinion and anecdotal information.” Reay et al. (2009) reported that

about 53.6% of reviewed published work on EBMgt make a case for or against EBMgt purely

from the author’s opinion, rather than offering any empirical evidence in either direction.

Therefore, for EBMgt to be successfully adopted and implemented, a significant need exists to

19
conduct more rigorous empirical research that demonstrates EBMgt impact or effectiveness on

organizational performance (Latham & Locke, 2009).

The Phase of Adoption or Implementation: 2013-Present

The advent of the healthcare reform law, i.e., the Affordable Care Act or ACA (Cogan,

2011), promotes the application of EBPs in healthcare institutions and mandates implementation

of accountable care organizations (CMS, 2014). Governing executive hospital officials are under

pressure to deliver high- quality, evidence-based healthcare to patients and to eliminate waste

and reduce medical costs (CMS, 2014). Additionally, a multitude of government health entities

has been advocating the incorporation of EBPs into healthcare settings. Entities such as

healthcare communities and regulatory agencies consider EBPs to be “the gold standard for the

provision of safe and compassionate healthcare” (Brown et al., 2009, p. 372). The Joint

Commission on Accreditation of Healthcare Organizations (2006; 2008) promotes incorporating

EBPs to enhance healthcare quality. Regarding the contribution of EBMgt to the overall

healthcare system, the Institute of Medicine considers EBMgt competencies to be essential for

healthcare managers and leaders of the 21st-century era (Greiner & Knebel, 2003). The U.S.

Agency for Health Research and Quality (2014) has created and dedicated evidence-based

practice centers that specialize in promoting EBPs.

Given the pressure that the ACA law, the requirement for healthcare providers to become

accountable, and the persistent advocacy of public health agencies that compel health providers

to practice EBPs, EBMgt has become an imperative in the U.S. healthcare system. Thus, senior

managers and executive leaders need to consider adopting EBMgt as an essential tool to help

them be accountable for delivering patient quality care and enhancing institutional performance.

20
 By integrating EBM and EBMgt into hospitals, for example, healthcare administrators

can play a significant role to show that EBMgt effectiveness can enhance quality healthcare

delivery and performance of healthcare institutions. Hence, hospital management and leadership

need to understand the ethical urgency and responsibility of embracing EBMgt. Therefore, it is

also important that hospital leaders understand that EBMgt, most importantly its integration with

EBM, might hold a significant place in creating a culture of evidence-based decision making.

Such a culture can lead to improved health firm performance (Shortell, 2006; Shortell et al.,

2007; Rundall et al. 2007; Champagne et al., 2014). To that end, Harland (2013) suggested that

managers must be able to conduct an evidence-based evaluation of management research to

examine its impact and implications on organization strategies and performance.

EBMgt Not a Common Business Practice

Rundall et al. (2009) stated that several healthcare providers, such as hospitals, have not

been using EBMgt consistently when making operational and strategic management decisions.

EBMgt constitutes an evidence-based approach for senior hospital managers and leaders to

utilize different forms of evidence such as the use of local business evidence, experiential

management evidence, and scientific evidence in a complementary manner. With EBM, many

models exist to facilitate medical staff implementation of EBM practices in hospitals (Gawlinski

& Rutledge, 2008). Unlike EBM, there is no standardized EBMgt model to help health

organization managers and leaders integrate EBMgt into their managerial practices. Several

studies on EBMgt, which are prescriptive and researcher-observational based, deal with barriers

to EBMgt implementation (Grol & Wensing, 2004). Executives of these institutions often rely

immensely on their personal experiences and intuition as primary sources of evidence for

management decision-making (Rousseau, 2006; Pfeffer, 2010). Rousseau (2006) reported that

21
most health executives do not support their decisions by scientific knowledge as evidenced from

management research findings. Although Tort-Martorell et al. (2011) agreed with these findings,

they maintain that with the emergence of EBMgt, many organizations now promote using

external knowledge sources in managerial decision-making.

EBMgt requires management and leadership use recent and reliable scientific evidence as

the basis for management decision making and good business practice (Wright, Nichols,

McKechnie, & McCarthy, 2012). However, Tort-Martorell and colleagues (2011) argued that

total quality management, which helps companies generate their organizations’ internal

knowledge, should continue to be the primary form of evidence that executives need to derive

scientifically adequate and sound decisions. Hence, with EBMgt being practiced both internally

and externally, it is essential to understand the reasons why executives of health organizations

have still not widely embraced the EBMgt movement or linked its implementation with EBM.

Factors Impeding EBMgt and EBM-EBM Integration

Wallington (2002) revealed that common barriers exist that prevent hospital executive

management teams from implementing EBM or EBMgt. Among these obstacles, Wallington

(2002) included factors such as lack of (a) time, (b) access to information, (c) training, and (d)

competencies and skills. Although public opinion expects physicians and nurses be required to

use EBM as a business practice in support of selecting the best medical interventions for patient

treatment, their senior managers and leaders continue to make decisions based on non-evidence

based practices (Tort-Martorell et al., 2011). Such discrepancy limits executive healthcare

leaders to not only implement EBPs in many hospitals but also to enable and build an evidence-

based culture. Thus, integrating EBM and EBMgt practices is necessary to create such a culture

(Shortell et al., 2007).

22
 Because EBMgt stands for utilizing existing research evidence to make effective

managerial decisions as good business practice, researchers still need to conduct more studies on

EBMgt, as well as on people’s behavior, to gain a thorough understanding of its impact on

organizational performance. In their exhaustive study of systematic reviews and meta-analyses

related to EBMgt, Jaana, Vartak, and Ward (2013) reported that limited relevant empirical

research evidence exists to make valuable and well-informed managerial decisions. They showed

that only 3% of the combined systematic reviews and meta-analysis studies on EBMgt existed in

management journals, implying that health management researchers still need to conduct further

research on EBMgt as most research on evidence-based practices deals with EBM (Knaapen,

2013).

Watts, Holzer, and Tritsch (2011) explained that EBMgt (or evidence-based research) has

many challenges. One of these challenges includes the need for EBMgt transparency to draw

from a broad range of empirical literature and make general conclusions that managers can

perceive as acceptable evidence in support of management practices (Watts et al., 2011).

Rousseau and McCarthy (2007) indicated that behavioral issues constitute some of the critical

factors precluding EBMgt practice. Therefore, organizations engaging in EBMgt need to know

how to identify and overcome these factors, including their organizational contexts (Guo, 2015).

Klimoski and Amos (2012) have cited the lack of evidence-based training or education as

one of the other reasons health leaders have difficulty embracing this concept in their daily

business practices. Klimoski and Amos (2012) indicated that it is challenging for organization

executives to become active in EBMgt if they have not received any formal training. Thus,

institutions, such as hospitals, need external change agents to help with promoting and educating

health executives concerning EBMgt and the culture of EBDM. Having the skills, knowledge,

23
and understanding of strategies to promote EBMgt may be paramount for facilitators or change

agents to help with the integration of EBM and EBMgt practices in healthcare organizations.

However, the need for healthcare organizations to have framework or model to help guide them

is considerable.

Evidence-Based Management Processes

Because EBMgt is a broad management approach, no universal or agreed-upon EBMgt

process exists (Briner et al., 2009). Toward this end, several scholars have suggested various

EBMgt process steps. Because EBMgt stems from EBM, Guo (2015) indicated there are no

fundamental differences in the processes between these two practices. Their principles are

similar because both rely on utilizing “the best available evidence, in conjunction with individual

expertise and clients’ values and concerns, to make informed decisions to improve the

effectiveness and efficiency of the performance” (Guo, 2015). Kovner et al. (2009) described

EBMgt as a six-step practice process that also reflects the steps included in the EBM process.

Marr (2010, p. 14) provided various ways or tips, including a five-step EBMgt sequence

process, a change agent might use to aid organizations in making effective business decisions by

embracing an EBMgt approach. These five processes were the key concepts Marr (2010, p. 14)

used in his EBMgt model that organizations can use to initiate EBMgt implementation. First, the

executive management has to understand the institution’s strategic aims to steer the EBMgt

process. Second, the organization executive team needs to collect relevant and meaningful data

to make well-informed strategic decisions. Equipped with these data, senior executive managers

can extract significant insights that are relevant to the context of their organization and support

its core strategic goals. This step consists in communicating gained information and insights to

all decision-makers through the organization while step five focuses on making sure all

24
appropriate management levels act to turn this knowledge into practical decisions or actions.

These five steps may provide the management executive with a blueprint for evidence-based

strategic decision-making. Transformational leadership is necessary for management to integrate

EBMgt practices into an institution’s culture (Marr, 2009).

Integration of EBM and EBMgt

EBMgt is a new management paradigm that stems from the practice of EBM in

healthcare systems (Pfeffer, 2010). Despite the growing EBM acceptance by clinical and

management leaders of healthcare institutions around the world, the adoption and the

implementation of evidence-based practices in management (i.e. EBMgt) still faces challenges in

healthcare settings (Squires et al., 2011; Rycroft-Malone, 2008). The slow embrace of EBMgt

practices, which occurs mainly at the management level, prevents healthcare organizations to

promote and develop a culture of evidence-based decision making in healthcare practices

(Domurad, 2005). With the practice of EBMgt, Pfeffer and Sutton (2006) declared that

executives would be able to utilize the most current available management research results and

theories to make evidence-based informed decisions that can improve institutional performance.

Therefore, to improve performance, EBM and EBMgt integration is paramount to ensure

evidence-based practices become the culture, not only for medical professionals (doctors and

nurses) but also for senior managers and executive leaders. Such integration will guarantee that

all Americans receive quality care based not only on EBM but also on EBMgt practices (Dopson

et al., 2002). However, most hospitals are having difficulties integrating EBM and EBMgt even

though both are critical to enhancing the value of care patients receive (Flynn & Fink, 2011).

Shortell, Rundall, and Hsu (2007) indicated that hospital leaders would contribute

significantly to improving American patient care and reducing its cost if they link both EBM and

25
EBMgt effectively. Thus, Guo (2015) agreed with these two scholars that consistent, sustainable

improvement in the quality of care received in the United States is unlikely to be achieved if

EBM and EBMgt are not linked together within effective health organizational contexts.

EBMgt and Organizational Contexts

In this 21st-century climate of accountability, executive leaders of most companies desire

to implement powerful management approaches, for example, approaches such as lean

management and others, to improve operational performance (Bortolotti, Boscari, & Danese,

2015). As a result, many institutions, including colleges and universities as Leimer (2012)

indicates, are engaging in developing EBDM culture. However, Ross, Beath, and Quaadgras

(2013) explained that shifting an existing organizational culture into an EBDM culture is

challenging and arduous. This change entails a lot of organizational changes, especially the

executive leadership and the whole system corporate culture (Leimer, 2012). These two

organizational factors can play a significant role in integrating EBM and EBMgt, as well as

implementing and sustaining the new EBDM culture. The findings from Ross et al. (2013)

showed that executives who develop an EBDM culture have easy access to available

performance data to make organizational strategic decisions. Thus, executives with access to

such data can distribute it to other organizational decision makers and obtain feedback in near-

real-time (Ross et al., 2013).

Culture of Evidence-Based Decision Making

Integration of EBM and EBMgt

According to the literature reviewed, a substantial number of published studies exist that

show it is time for healthcare organizations to integrate EBM and EBMgt in support of

developing EBP contexts that foster a culture of EBDM. McCormack et al. (2002) maintained

that EBP context is “the specific environment in which implementation, utilization, and the
26
creation of evidence may take place” (p. 101). The EBP context has three components: (a)

organization culture, (b) leadership, and (c) measurement (evaluation). From the work of

Cummings et al. (2008), Gallagher-Ford (2014) asserted that researchers understand that

organizational context is critical in implementing EBPs. The organizational context is also

essential to creating a culture in which management research findings are valued, expected, and

where opportunities for dialogue and collaboration between managers, executives, and

employees prevail. Hawkins (2013) noted that executives need to engage in this process because

it helps the organization identify barriers and needed internal facilitators for implementing

EBMgt and developing its sustainability strategies that will produce the most valuable

integration. By so doing, healthcare organizations will contribute to bridging the gap between

their use of management research evidence and administration practices.

For such a change to occur in the health system, chief executives and chief administrators

need to develop a culture that requires managers to use relevant research evidence in support of

making effective business decisions (Kovner & Rundall 2006; Pfeffer & Sutton, 2006; Rousseau

et al., 2008; Walshe & Rundall, 2001). Some scholars maintain that implementing a purely

scientific approach like EBMgt cannot effectively solve management problems. Instead of

legitimating a universal best practice as EBMgt advocates do, critics caution that management

researchers also need to consider the critical role organizational politics plays in healthcare

settings (Gkeredakis et al., 2010). Politics of organization influence how managers make

decisions and decide what evidence is and how and why the organization can use it (Kovner et

al., 2009). Despite criticism, Morrell, Learmonth, and Heracleous (2015) believe that EBMgt

will overcome the current problems it faces just like the EBM movement did.

27
Organizational Leadership and EBMgt

Reichenpfader, Carlfjord, and Nilsen (2015) maintained that healthcare organization

leadership must play a critical role in implementing EBMgt in health settings. From reviewing

17 studies, they found, “Leadership was mostly viewed as a modifier for implementation

success, acting through leadership support” (p. 308). Because many scholars regard leadership as

one of the particular organization’s contextual dimensions of EBMgt implementation (Taylor et

al., 2011; Stetler et al., 2011), it is essential to investigate how leadership, including organization

culture, might contribute to developing an EBDM culture in hospitals.

Implications for EBMgt and EBM Integration

Evidence-Based Management Culture

It is paramount that EBMgt scholars and practitioners consider working collaboratively

with senior hospital officials to understand the practical and functional complexity of the

multilevel issues that management and leadership face daily to promote EBMgt successfully

(Madhavan & Mahoney, 2012). Potworowski and Green (2012) declared that an organization’s

cultural environment shapes its EBMgt process. Toward this end, Speicher-Bocija and Adams

(2012) have examined the challenges and benefits of EBMgt implementation.

Hospital Strategic Decisions

Hospital strategic decisions constitute a priority for senior management executives since

these officers determine strategies needed to accomplish the hospital’s mission and objectives.

For this reason, it is essential to understand how senior hospital leaders and managers use

evidence resulting from EBMgt and EBM evidence-based principles to make strategic decisions

required to organize, structure, and deliver quality healthcare for the communities they serve.

Stetler et al. (2014) asserted that senior executives engage in strategic behaviors when planning

organizational change and aligning institutional goals with its mission and vision. Hence, as Gale

28
and Schaffer (2009) explained, many healthcare organizations must strive in balancing EBPs

with their contextual practices. EBPs may help explain the sources of evidence that have

influenced leaders’ strategic decision-making process regarding hospital clinical program

expansion, organizational partnership, and quality of care.

Ledger (2010) notes that organizational and management researchers have been

extensively studying how organizational leaders make strategic and operational decisions.

Although EBMgt alone does not provide solutions to 21st-century problems that hospitals face

today, just like EBM, EBMgt provides some transparency that makes organization decision-

making processes traceable (Ledger, 2010). Ledger (2010) asserted that these two concepts,

which are not equivalent, constitute complementary means that hospitals can use to leverage the

clinical and non-clinical knowledge required to improve healthcare delivery. Thus, EBMgt is an

approach or tool that hospital decision-makers need to use to challenge the evidence or

knowledge sources used in making strategic decisions.

EBMgt and Healthcare Organization Performance

Speicher-Bocija and Adams (2012) claimed that with the awareness of the various

benefits EBMgt brings to organizations, hospital executives might be encouraged to embrace and

use EBMgt to make more efficient management decisions. Despite the significant advantages

that EBMgt promises, Speicher-Bocija and Adams (2012) noted that health or corporation

executives still have difficulties incorporating management research evidence findings into their

organizations’ managerial and business practices. For EBMgt to become a reality, Rousseau

(2012) recommended that healthcare executives collaborate with educators, researchers, even

though “EBP is what practitioners do” (p. 18). The collective contribution of these three forces

can create the needed infrastructure to make EBMgt implementation a reality by facilitating the

development of processes and practices required to accelerate research uptake into practice
29
(Rousseau, 2012). As Hodgkinson and Rousseau (2009) reported, such collaboration is essential

for creating research knowledge that is relevant and rigorous for both practitioners and

management researchers.

Integrated Conceptual Model for Developing a Culture of EBDM

In searching for an integrated framework to guide this research endeavor, this study built

upon the theoretical framework of three theories. These were as follows: (a) organizational

change conceptual framework, (b) diffusion of innovation theory and the transtheoretical stages

of change model, and (c) promoting action on research implementation in health services

Organizational Change Theoretical Framework

In this study, the author perceived “organizational change” as a persistent and consistent

effort that healthcare executives can use to help their institutions extend their competitive edge

and growth in this extremely competitive global market environment of the 21st-century. The

organizational change framework is necessary. As Armenakis and Harris (2009) noted, first it

can help leaders consider some of the most practical issues that hospitals may face when

attempting to incorporate EBMgt in their practices. Because EBMgt is a nascent movement, one

needs to grasp the various research themes that Armenakis and Harris (2009) have advanced as

follows: first, how to identify the key change beliefs within an organization; second, how to

stress involvement and participation of the organization’s officials in the change effort; and third,

how to conduct an effective diagnosis of why the change, i.e., EBMgt, is essential for managers

to include in their decision-making processes. Another theme is how to help create

organizational readiness for an organization to embrace an EBMgt culture. Finally, how to assist

practically healthcare firms (hospitals) in developing EBMgt managerial competencies.

30
Diffusion of Innovation Theory and the Trans-Theoretical Stages of Change Model

Viewing EBMgt “as a technological innovation” as Speicher-Bocija and Adams (2012)

proposed offered another lens or perspective through which to argue for adopting EBMgt.

Drawing from the diffusion of innovation theory and the transtheoretical stages of change model,

this researcher agreed with Speicher-Bocija and Adams (2012) that it is critical to reject the idea

that “managers do not use evidence in their day-to-day decision making” (p. 294). To work in a

participative project with health administrators, one has to recognize that these executives

already use evidence in their decision-making process when they leverage their professional

expertise and personal judgment (Speicher-Bocija & Adams, 2012). However, Speicher-Bocija

and Adams (2012), as well as the researcher of this study, agreed with proponents of EBMgt that

company management does not readily integrate recent scientific evidence from a management

research base into decision-making processes. Hence, this study explored this framework to find

strategies or a model to help encourage, promote, and facilitate practicing EBMgt to accelerate

the uptake of evidence-based research into hospitals, as Speicher-Bocija and Adams (2012) have

proposed doing in other corporations.

According to Speicher-Bocija and Adams (2012), the model of the innovation diffusion

theory and transtheoretical stages of change provides an excellent guide to helping management

accelerate not only adopting EBMgt in management practice but also developing an EBDM

culture. Even though the study of Speicher-Bocija and Adams (2012) can contribute to propose

strategies for implementing EBMgt, it is still prescriptive, which is a weakness, like many other

EBMgt investigations. Speicher-Bocija and Adams (2012), proponents of EBMgt, proposed how

to design processes to advance EBMgt practice while leaving out the inputs from senior

managers and leaders. Members of senior hospital senior management are the hospital

practitioners who can make EBMgt become a reality. However, Speicher-Bocija and Adams
31
(2012) contributed a new perspective to the literature on EBMgt by looking at it from the

framework of innovation diffusion theory and transtheoretical stages of change model.

Promoting Action on Research Implementation in Health Services

A third conceptual framework this study examined was the model of promoting action on

research implementation in health services or PARIHS (Brown & McCormack, 2011; Cummings

et al., 2010; Hagedorn & Heideman, 2010; Schultz & Kitson, 2010). This framework, according

to Reichenpfader et al. (2015), provides diversity on how leadership plays a role to promote the

uptake of management research during EBMgt implementation in healthcare settings.

Conceptual Framework

To guide his research inquiry, the researcher formulated a conceptual framework based

on an extensive literature review of EBMgt. This conceptual framework, illustrated in Figure 1,

provides direction for the overall research question. As noted earlier in this study, EBM (content)

and EBMgt (context) are key components of EBPs for health providers to deliver high-quality

care (Bell, 2011). However, hospitals still experience challenges implementing an EBM model

of care and integrating it with EBMgt (Shortell et al., 2007; Sackett et al., 1996). For hospitals to

succeed in adopting and implementing new management practices, the C-level leaders need to

regard their organization as a whole system (Titler, 2008). For this reason, they have to engage in

transformational leadership and EBMgt practices (Page, 2004) to provide the support required

for implementing EBPs throughout the healthcare setting.

32
 Common Clinical Practice
Healthcare practitioners:
- Doctors
- Nurses
Not currently evident - Other medical professionals

Evidence based medicine

evidence through hospitals

Organization Leadership

Management culture as
C-Level Hospital Leaders:-

in the Denver Area

- CEOs

Evidence Based
- Senior executive managers
Research Question: What can we learn
from high-performing hospitals about
how to implement systematic evidence
based management in hospitals?

Healthcare Organizations (hospitals) in the Denver Metropolitan Area

Figure 1. Conceptual framework

Hospital leadership is critical for promoting EBMgt and EBM practices. These practices,

especially EBMgt, require a transformation not only of the organizational strategies, structures,

and management practices (environment) but also of perceptions and beliefs, including executive

leader and other professional practices. These executives are also responsible for defining proper

implementation practices that support new organizational initiatives. To ensure hospital success

in embracing both EBM and EBMgt, the engagement and commitment of organization leaders in

adopting and implementing these two concepts can guarantee the critical incorporation of new

hospital practices and organizational strategies (Burke, 2011; O'Reilly et al., 2010). EBMgt

constitutes a systematic approach that is essential to effective management and data-driven

decision making that must start with the top leadership team to ensure executive decisions focus

on five key hospital business indicators or areas (Voelker, Rakich, & French, 2001). These areas

33
are (1) mission, (2) stakeholders, (3) financial and operational performance, (4) internal

processes, and (5) learning and growth (Voelker et al., 2001).

Even though hospitals are healthcare organizations whose role primarily includes

providing high-quality and safe care to the communities they serve, C-level hospital leaders also

have the responsibility to ensure financial sustainability and ethical business practices related to

delivering efficient healthcare. With this perspective in mind, Hofmann (2010) indicated that

hospital senior executive leaders have to consider the slow and uneven adoption of EBMgt (i.e.,

best management practices) and EBM (i.e., best clinical practices) as a critical ethical issue for

hospitals. Also, because of limited economic resources hospitals face, using EBMgt is more

imperative than ever before (Hofmann, 2010). Mastal, Joshi, and Schulke (2007) argued that

executive leaders play a critical role as change agents in transforming hospitals into EBMgt

health settings. Since the enactment of the ACA, the American healthcare delivery system is

changing drastically in that C-level hospital leaders must now embrace EBMgt, including the

transparency and transformational leadership it requires, to help their institutions adapt to the

ever-changing healthcare business environment.

By using EBMgt approaches, such as the balanced scorecard, hospital management, and

leadership teams can leverage the power of communicating and collaborating to share relevant

information (evidence) needed to make evidence-based decisions throughout the institution. To

ensure hospital success in embracing both EBM and EBMgt, the engagement and commitment of

organization leaders with adopting and implementing these two concepts can guarantee

incorporating critical new hospital practices and organizational strategies (Burke, 2011; O'Reilly

et al., 2010). The conceptual framework, as illustrated in Figure 1, derived from an extensive

literature review of EBMgt and EBM. Thus, EBM (content of providing care) and EBMgt

34
(context of providing care) are key components of EBPs for health providers to deliver high-

quality care (Shortell et al., 2007). Senior executive management (leadership) of hospitals plays a

significant role in implementing EBMgt and EBM practices. For hospital strategic decision-

making to benefit from evidence of both, leaders and managers need to integrate these two

constructs. Yackel et al. (2013) asserted that implementing evidence-based practices provides

strategies for hospitals not only to achieve sustainability but also to establish a culture of

evidence-based strategic decision making.

With leadership transparency that EBMgt creates, healthcare leaders at all organizational

levels can engage in the decision-making process through using the balanced scorecard, an

integrated management tool, to commit to a culture of evidence-based decision making and

organizational performance. Using the balanced scorecard as “an integrated and iterative

strategic management system,” as Voelker et al. (2001) suggested, healthcare organization

leaders have an excellent platform (framework) implementing EBMgt and EBM to generate

information (data) needed to link their hospital strategies with organizational performance. Daly

et al. (2014) explained that for successful implementation to occur in an organization, executive

leadership must remain engaged and committed to those practices, which includes EBMgt and

EBM in this study. Thus, the executive management team must work closely with senior and

subordinate leaders to ensure its commitment to implementing new practices. This observation

also applies to the context of implementing both EBM and EBMgt. Hence, with this research

project, the research explored how EBMgt influences hospital leader practices to promote the

uptake of new management practices that can improve the quality of healthcare provided. It is a

significant challenge for hospital leaders to institutionalize evidence-based practices, such as

EBMgt and EBM, to make them become organizational realities (Stetler, Ritchie, Rycroft-

35
Malone, & Charns, 2014). These management executives have a considerable influence on

implementing these two evidence-based principles in their organizations (Sandström, Borglin,

Nilsson, & Willman, 2011).

Management Researchers and EBMgt Implementation

With extensive experience in healthcare and leadership management research, the

researcher played a role in helping implement EBM and EBMgt. Bansal et al. (2009) asserted

that a researcher could play a significant role in helping an organization implement EBMgt

practices to bridge the research-practice gap. Hence, a scholar should have the skills to perform

three distinct functions: (a) facilitating, (b) convening, and (c) supporting EBMgt

implementation (Bansal et al., 2009). As a convener, researchers need to initiate collaboration

between EBMgt stakeholders of an organization to discuss issues of scientific decision-making

processes. With the skills of a supporter and facilitator, the researcher was able to provide

support and cooperation, respectively, with helping communication, negotiation, and problem-

solving between involved parties. A collaboration between researchers and management

practitioners may contribute to producing sound empirical studies rather than promoting EBMgt

from literature reviews that are solely descriptive (Tranfield et al., 2003). Tourish (2013)

remarked, as a result, practitioners often misunderstand and misuse management research

findings because such research is difficult to generalize and to interpret. Briner et al. (2009)

stated that EBMgt is a family of approaches that support decision-making in many organizations.

Thus, a researcher or scholar significantly contributes to establishing a foundation or

infrastructure needed to implement EBMgt (Briner et al., 2009). In this regard, Briner and

colleagues’ work corroborates with Bansal et al. (2009) findings. These results indicated that the

researcher’s knowledge and skills as a scholar and educator are crucial to helping health

organizations produce, evaluate, synthesize, and create access to research evidence. In this
36
regard, the researcher may contribute to the development of an EBMgt culture in any institution.

Thus, one needs an in-depth understanding of how hospital senior officials in Colorado perceive

the impact and benefits of adopting EBMgt practices and integrating EBM.

An integrated hospital leadership (i.e., management leaders and medical staff leaders) is

necessary for a healthcare organization to adopt new evidence-based practices that can improve

quality, reduce delivered healthcare costs (AHA & AMA, 2015), and enhance the overall

organization performance. It is evident that adopting EBMgt and EBM practices might be

essential in eliminating or reducing overuse, underuse, and misuse of hospital resources (AHA &

AMA, 2015). Integrating these two evidence-based principles is also paramount for hospitals to

foster effective collaboration between leaders of management and clinical medical staff to make

hospital evidence-based strategic decisions and to improve hospital performance.

Summary of Literature Review

Chapter Two offered the readers an in-depth review of the current EBMgt status in the

American healthcare system. It reviewed the existing literature on the topic of EBMgt and

provided several definitions. It also examined the process of EBMgt and its integration as two

constructs needed to create an organizational environment conducive to an EBD culture. Various

factors influencing EBMgt implementation in healthcare organizations was also presented. Thus,

one can view EBMgt as a practicing model of best available management research evidence to

help hospitals make better management decision and improve the quality of care as well as

organizational performance. However, findings from existing research show that most American

healthcare settings have not widely used or implemented EBMgt or EBM. Despite the rapid

progress that many hospitals have made by embracing EBM, they have been slow in

incorporating EBMgt into their business practices. According to Guo (2015), the variety of

37
beliefs, attitudes, and behaviors that these administrators still hold in regards to this new way of

thinking (EBMgt) may explain the slowness and reluctance of health executives to embrace

EBMgt and EBM integration. Thus, the EBMgt field still needs to develop theoretical

frameworks to help guide health leaders in the practice of EBMgt to make EBP culture pervasive

in the American healthcare system.

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 CHAPTER THREE

The goal of this investigation was to learn from high-performing hospitals in the Denver

Metropolitan area and to understand how executive leaders and managers use or combine (or

not) both EBMgt and EBM in support of improving quality and institutional performance. Thus,

this study explored adopting and implementing EBMgt, including its integration with EBM, and

the perceived influence of EBMgt-EBM integration on strategic decision-making processes and

hospital performance of these organizations. This study also explored what senior hospital

leaders viewed as the critical contextual factors that impede or favor integrating EBMgt and

EBM in hospitals and health systems that simultaneously implemented safety and quality

improvement initiatives.

Begun, Kaissi, and Sweetland (2005) conducted a similar exploratory research to

understand healthcare strategic planning of hospitals in two Metropolitan areas, St. Paul

(Minnesota) and San Antonio (Texas). Such exploration served as a starting point to understand

the vital role hospital transformational leadership plays in implementing EBMgt and its

integration with EBM to accomplish the necessary changes needed to improve organizational

quality and performance. Implementing these two evidence-based principles in hospitals is a

critical strategy for enhancing quality healthcare, stakeholder satisfaction, and organizational

performance (Melnyk, Fineout‐Overholt, & Mays, 2008). The quality of healthcare delivery in

the 21st century is both a clinical practice as well as a management and leadership challenge

(Xiao, Savage, Davis, & Zhuang, 2009).

The current chapter outlines (a) the research design project; (b) the population, sampling

method, and participants; and (c) the study procedure. It also discusses (d) instrumentation, (e)

trustworthiness and credibility, (f) data collection, and (g) data analysis. Furthermore, this

39
chapter also presents some of the ethical considerations while conducting management research

in healthcare settings (hospitals), including a summary of Chapter Three.

Research Traditions

The CTU dissertation template stated that “Every research design has its roots in one or

more established research traditions” (CTU, 2016, p. 7). With this idea in mind, the researcher

assessed the applicability and integration of existing research traditions to the research project

and, as such, chose qualitative inquiry. A qualitative research tradition, according to Yilmaz

(2013) is “an emergent, inductive, interpretive and naturalistic approach to the study of people,

cases, phenomena, social situations and processes in their natural settings to reveal in descriptive

terms the meanings that people attach to their experiences of the world” (p. 312). With

qualitative methods, researchers can gain richer and in-depth information to understand the

context and meaning of the phenomenon they are investigating (Patton, 2002; Sofaer, 1999) in

settings with complex interactions of people such hospitals (Eccles, Grimshaw, Campbell, &

Ramsay, 2003). It is essential to bear in mind that the qualitative research tradition uses several

methodologies that vary based on the researchers’ discipline or field of study (Denzin & Lincoln,

2005).

Because managerial practices vary depending on the contextual factors of each

organization (Gill & Wong, 1998; Gooderham, Nordhaug, & Ringdal, 1998), there might be

some common approaches to EBMgt that are more transferable between different hospital

settings while others may not. Also, EBMgt implementation, just like other EBM requires the

involvement of several key stakeholders within or between organizations (Palinkas et al., 2015).

In light of Palinkas’, this study was suitable for an exploratory, qualitative inquiry approach

because it sought to learn how senior hospital leaders in the Denver Metropolitan area are

implementing EBMgt and EBM practices according to their specific organizational contexts.
40
Also, because of the scarcity of available published works on EBMgt and EBM integration,

including this investigator’s limited knowledge about the issue, an exploratory study was

appropriate (Manerikar & Manerikar, 2014). This initial exploratory research played an essential

role in identifying and defining problems or concepts needed to crystalize integrating EBM and

EBMgt. Manerikar and Manerikar (2014) noted that such understanding would be paramount for

helping to determine variables and hypotheses to use in future quantitative inquiries that will be

more rigorous and conclusive.

Research Question

As stated in Chapter One, the current study explored the following overall research

question: What can be learned from senior hospital executives and health systems in the Denver

metropolitan area about how to systematically implement EBM-EBMgt?

Research Design

According to Myers (2008), a research design is a means of collecting and analyzing data

and interpreting and disseminating results. This academic investigation used a qualitative

exploratory research design to define the participants and context of the project as Malagon-

Maldonado (2014) suggested. Delost and Nadder (2014) explained that a researcher has to ensure

research questions or hypotheses that derive from gaps in the existing literature are included to

drive the study’s research design. Because publication of the work is focused on “improving

patient care by linking evidence-based medicine and evidence-based management” (Shortell et

al., 2007), EBMgt and EBM integration is still uncharted territory. As such, the researcher chose

an exploratory, qualitative method to derive broader issues related to EBMgt and EBM

integration that hospitals face from a smaller number of participants through in-depth interviews

(Perry et al., 1999). According to Holloway and Wheeler (2013), a qualitative inquiry allows the

researcher to explore participants’ behavior, perceptions, and experiences about a given

41
phenomenon. This exploratory investigation explored the experiences of hospital decision-

makers with EBMgt and its integration with EBM to extend the study’s initial effort mentioned

earlier to open new research opportunities.

This academic research endeavor used semi-structured interviews as a tool to ask senior

hospital executives questions about their understanding and perceptions of EBH phenomenon

and integration (i.e., the content of providing care) and EBMgt (i.e., the context of providing

care) in hospitals. This exploratory, qualitative research may help gain an operational

understanding and definition of EBMgt for hospital executives to include how EBMgt-EBM

integration may serve as a tool for senior hospital leaders in making strategic management

decisions that can improve quality and performance. Since the EBMgt research field in general,

and the integration of EBMgt and EBM in particular, is still in its infancy, a qualitative approach

was suitable for this study to learn how leaders in the Denver Metropolitan healthcare setting

help integrate EBMgt and EBM (or not). Toward this end, the findings of this exploratory study

may help inform future research by defining variables in support of developing inductive and

deductive hypotheses (Khon, 2013).

Population and Sample

Population

Today’s hospitals are complex, large institutions that require not only leaders with

specific management competencies (Kovner and Rundall, 2006), but they also work

collaboratively to define and promote the mission, vision, and goals of their entity. Hospitals are

complex healthcare settings where leaders, members of the governing body and the C-suite

(Chief executive officer and other senior administrators), work collaboratively to define and

promote the mission, vision, and goals of their institutions (McInnes, Phillips, Middleton, &

Gould, 2014). Senior health officials play a significant role not only in ensuring patient safety

42
but also in designing and operationalizing hospital quality improvement programs (McInnes et

al., 2014).

Hospital senior leaders in the Denver Metropolitan area constituted the targeted

population of this study because they were most likely familiar with the various management

practices and organizational performance metrics of hospitals and health systems. Thus, study

participants were senior healthcare management executives, directors, and managers of hospitals

who operate in the Denver Metropolitan area (Colorado). Senior hospital decision-makers

comprised clinical and non-clinical executives who participated in hospital strategic decision-

making and managed some hospital services and divisions. These hospital management

executives (or senior leaders) included (a) CEOs, (b) chief administration officers, and (c)

department directors, to include some senior clinical and non-clinical managers as Carter, Lonial,

and Raju (2010) suggested. For this study, chief administration officers consisted of hospital

management title positions such as chief operating officers (COOs), chief medical officers

(CMOs), chief nursing officers (CNOs), and chief clinical officers. This study included hospital

executive directors of medical services, nursing, medical affairs (Dwyer, 2010), and community

relations depending on the organizational structure of each health practice setting. The

participants needed to have at least two years of previous management experience (within their

current hospital) to participate in the final study sample. To ensure the study’s final targeted

population included senior executives, the investigator considered senior leaders meeting the

Fellows status of the American College of Healthcare Executives (ACHE, 2016).

Three U.S. institutions, (1) Malcolm Baldrige Program (Baldrige, 2015; Schaefer, 2011),

(2) the Thomson Reuters “Top 100 Hospitals” (Shook & Chenoweth, 2012), and (3) the Magnet

Recognition Program (Heitmann, Čišić, & Meyenburg-Altwarg, 2013) recognize the best U.S.

43
hospitals. They award hospitals and health systems for the excellence of the quality of their

clinical practices, leadership, and patient safety practices (Geisler, Krabbendam, & Schuring,

2003, Porter-O’Grady, 2007). For this study, the investigator interviewed leaders from hospitals

and health systems in the Denver metropolitan area that won at least one of the high and

prestigious recognitions mentioned above. These winning-award organizations constituted the

setting of this study’s research project because of the leadership commitment and engagement of

such high performing institutions to adopting and implementing new business practices as

Chassin and Loeb (2011) indicated. These healthcare organizations constituted unique settings in

which a significant amount of both EBMgt and EBM use existed.

Sample Size

The current study included the perspectives of 13 senior hospital and health system

decision-makers in the Denver area. Because sampling is critical to the overall success of a

research project (Tuckett, 2004), the researcher’s goal was to use a purposive sampling approach

to select and interview 8-12 participants for the exploratory research inquiry (Steinberg, 2008;

Teddlie & Yu, 2007). Steinberg (2008) explained that the sample size of 10 participants in an

exploratory study is appropriate because qualitative methods are more concerned with exploring

a phenomenon in depth to uncover themes, constructs, and associations rather than with its

representativeness of the target population. The purposive sampling was essential to ensure all

participants were health professionals with the required expertise and knowledge associated with

hospital management and leadership. Although the exact number of participant interviews

depended on reaching the point of information saturation (Strauss & Corbin, 1998); Guest,

Bunce, and Johnson (2006) have demonstrated that in most qualitative studies, data reached

saturation within 12 interviews. For this study, the researcher assessed that the number of 13

44
interviews was enough to ensure a 95% level of confidence that all relevant emerging themes

were held by at least 20% or more of the sampled population as Galvin (2015) suggested.

Sampling Procedure

As a member of the American College of Healthcare Executives and the Colorado

Hospital Association, the researcher leveraged or gained access to hospitals in the Denver Area

through these memberships. The investigator obtained a list of executive healthcare leaders

containing emails, phone numbers, and job titles, including names of the health institutions via

the American College of Healthcare Executives’ membership directory to start establishing

contacts with potential participants. The researcher performed his initial solicitation of

participants via a formal invitation letter (see Appendix A), which he sent by email, and then

followed up by subsequent phone calls and emails. An informed consent form (see Appendix B)

stated that the study’s purpose and confidentiality accompanied the invitation letter in the same

initial contact email sent to participants. In the invitation letter, the investigator provided an

email address and mobile phone, as well as of the researcher’s mentor, so that participants could

respond to express their willingness (or not) to participate in the study. The email approach,

followed with subsequent phone calls, was chosen to ensure the researcher could reach a

significant number of hospital executives in a relatively short and faster timeframe to schedule

face-to-face interviews.

Upon completing the interviews with top participating executive leaders of each selected

health system, the investigator also utilized a purposive sampling strategy with snowballing

(Palinkas et al., 2015; Patton, 2002) to identify other senior executive leaders who could partake

in the organization’s strategic decision-making process. By so doing, the study’s sample

extended to senior managers (clinical and non-clinical) who make critical decisions that inform

45
hospital strategic management. This procedure allowed this researcher to select participants

purposefully and to include only those thought to have practical experience and knowledge of the

research phenomenon (Palinkas et al., 2015)—in this case, EBMgt and EBM. A purposeful

sampling strategy was ideal to gain in-depth insight that can provide breadth of understanding to

the research problem (Kemper, Stringfield, & Teddlie, 2003). Because hospital leaders are highly

busy, such an approach was necessary to generate information needed for the investigation in a

relatively short time with minimal cost. This study assumed that the leaders selected for the

qualitative interviews were representative of senior executives’ and health systems’ roles in the

Denver Metropolitan area.

Instrumentation

As stated earlier, this exploratory study used qualitative interviews to gain insight into

senior hospital leaders’ perception on EBMgt implementation with EBM. Due to its exploratory

nature, interviews were the main instrument for data collection concerning leaders’ knowledge

and perceptions toward EBMgt-EBM integration. The investigator used an interview protocol

guide to conduct a series of one-on-one interviews with study participants. This interview guide

(Appendix C) adapted categories of questions found in reliable and validated research

instruments been previously established in the literature to develop semi-structured interview

questions. Hence, the study interview questions derived from validated tools such as

Organizational Culture and Readiness for System-Wide Integration of Evidence-Based Practice

(OCRSIEP) that Fineout-Overholt and Melnyk (2006) have developed and the Evidence-Based

Practice Beliefs (EBPB) Scale (Melnyk, Fineout-Overholt, & Mays, 2008). The study also

derived additional questions from the validated Evidence-based Management Attitude Scale that

Bosman (2015) has proposed. Therefore, conducting a pilot study was necessary for this research

project.
46
Pilot Study

The investigator undertook a purposeful pilot study involving five healthcare researchers

and practitioners to validate the research interview questions before to conducting the study in

healthcare settings. Pilot study participants ensured that the interview protocol included specific

questions, free of errors and areas of confusion, to help senior hospital managers provide relevant

and credible information about EBMgt practices in hospitals. The five healthcare management

researchers and practitioners who took part in the pilot study were purposefully selected but did

not participate in the study sample. The study investigator tested the interview protocol with

three non-participating local hospital managers in Denver. Pilot study participants helped check

the study interview protocol to guarantee that the questions would contribute to detecting and

codifying the potential various emerging themes.

Interview Questions

A series of open-ended interview questions helped capture each participant’s perspective

and understanding of practicing EBMgt as a supporting management philosophy to EBM that

can enhance organizational performance (Shortell, 2006). Interviews included open-ended

questions to elaborate on the why and how, as well as the various challenges hospital leaders

face in their positions as executives to implement EBMgt (Larson, Latham, Appleby, &

Harshman, 2012) and its integration with EBM practices. These interviews, which included male

and female healthcare executives, varied between 25-60 minutes in duration and were audio

recorded and transcribed (Creswell, 2014). The interview protocol served as a guide to the

investigator as well as to the participants during the interview process (De Ceunynck,

Kusumastuti, Hannes, Janssens, & Wets, 2013) to ensure health executives responded to the

same questions. These interview questions aimed to explore how hospitals in the Denver

Metropolitan area use evidence from EBMgt and EBM to adopt new clinical and management

47
practices in support of improving their overall quality, operational and strategic management,

and performance. The study asked participants the following semi-structured, qualitative

interview questions:

1. To what extent would you say you are using EBMgt in your current leadership decision-

making position? Can you give examples of how EBMgt is benefiting management

practices?

2. What is your perception of your organization’s practice in linking EBMgt and EBM practices

to provide better care?

3. What do you think about the impact of EBM and EBMgt integration practices on your

organization’s performance?

4. How do you feel about the influence EBMgt-EBM has on transparency and accountability of

senior leaders’ decision-making process in your hospital’s strategic decisions?

5. How do you think the integration of EBM and EBMgt practices will change the beliefs and

attitudes of other CEOs and other senior leaders?

6. What role do you think the combination of EBMgt and EBM plays in the development of an

evidence-based decision-making culture in your organization?

7. How do senior executives make sense of evidence from EBM and EBMgt in your hospital?

What is the process you use?

8. What factors do you perceive to be the most important, barriers and facilitators, for a

systematic integration of EBMgt and EBM to occur in healthcare practice?

9. Can you please describe a typical way in which your institution uses evidence from both

EBMgt and EBM to make strategic decisions in each of these three areas—core business

transactions, operational management, and strategic management?

48
 Using the earlier identified exploratory interview questions, the researcher hoped to

determine the research problems and variables that were determinants for adopting and

implementing EBMgt and EBM in hospitals of the greater Denver area. Thus, it was essential to

ensure the validity and reliability of the interview protocol to consider it as a credible research

tool or instrument for this study.

Credibility and Trustworthiness

To ensure the trustworthiness of this study’s findings, the researcher had to guarantee that

the data collection instrument (interview protocol guide) would efficiently measure what it

intended to measure (Dillman 2010). That included hospital leaders’ perceptions and

understanding of EBMgt implementation and integration with EBM. As Polit and Beck (2014)

indicated, trustworthiness consists of the following components: credibility, transferability,

dependability, and confirmability. For a qualitative study, a researcher must establish validity

and trustworthiness by demonstrating data accuracy that represents participants’ views and

interpretation (meaning) of the phenomenon studied (Chenail, 2011).

Credibility ensures data accuracy that the study findings are believable. Healthcare

executives who participated in the study had the necessary professional expertise and experience

to provide the investigator with reliable and credible information to support the study’s findings.

The study targeted health system leaders with expert knowledge in hospital management

practices and issues. Transferability, the transfer of the applicability of the results of the research

to other contexts, including its dependability and confirmability, were also evaluated (Bryman &

Bell, 2011).

The researcher used strategies such as triangulation, thick description, and reflexivity to

increase the trustworthiness and credibility of this study’s findings (Creswell, 2014, Polit &
49
Beck, 2012). To ensure this study’s trustworthiness, the investigator remained engaged with

available hospital leaders (participants) to build trust and foster rapport that provided rich and

detailed interviewee input. Such trust was indispensable to obtain participant feedback about data

accuracy while interpreting emerging themes. By so doing, the researcher was able to validate

the study’s conclusions. Having study participants check the findings reassured the investigator

that any personal values and biases did not affect the study. The researcher also used

triangulation to help identify converging themes from participants’ interview responses, the

researcher’s observation, and field notes (Casey & Murphy, 2009; Cope, 2014).

Reliability

Qualitative research does not generate the exact replicability as the reliability of a

quantitative inquiry. Doing so would require conducting an investigation in similar settings

(Corbin & Strauss, 2008). Nevertheless, qualitative researchers still need to address reliability in

their studies. Because hospitals and healthcare systems are complex social and contextual

environments, the study investigator readily understood that key issues related to EBMgt

implementation and EBM integration would vary among participants within and between

organizations. Therefore, to help ensure the reliability of interviews, the researcher used an

interview protocol guide, as previously indicated, to ensure participants received the same

research questions. As a result, in this study, reliability equated to the consistency of the research

instrument (interview guide) to yield similar ontological data that could differ in their “richness

and ambiance within similar dimensions” (Carcary, 2009, p. 11). Thus, to enhance reliability,

this health management researcher continuously conducted data comparisons to ensure an

accuracy of participants’ responses, transcription, and triangulation (George, & Apter, 2004).

50
 Data Collection

As the interviewer, the study investigator conducted face-to-face semi-structured

interviews to collect data (Creswell, 2014; Patton 2002). No additional data sources were used to

provide the researcher a broader view of perspectives related to the research topic as some

scholars have proposed (Creswell, 2014; Yin, 2009). Hence, interviews were tape-recorded, and

the researcher made personal observations taking notes during the interview process. Interview

questions, including subsequent follow-ups and answers, were recorded using a digital Sony

ICD-UX533 recording device. Depending on each interviewee’s expertise and knowledge, the

length of interviews varied in length between 30 and 60 minutes.

Interviews began with the investigator providing the participants an introduction. To

prevent influencing interviews with personal biases, the researcher carefully listened, allowing

participants to respond to open-ended interview questions. During the data collection process, the

investigator and the participant probed each other for clarification purposes to ensure a collection

of valid information that can provide a better understanding of hospital leader perceptions about

linking EBMgt and EBM.

The investigator transcribed recorded interviewed, checked transcripts against tapes for

accuracy, and ensured transcriptions were free of errors. By so doing, the researcher became

familiar with the research project data. Upon completing the interviews, the investigator made

sure he treated the collected data with complete confidentiality with the intent to protect the

participants’ identities and rights.

The investigator addressed and maintained participant data confidentiality by using a

256-bit encryption FIPS 140-2 level 3 compliant USB drive. The researcher digitally uploaded

and stored all information (from written notes and audio recorded interviews) onto this encrypted

device immediately upon completing interviews. The researcher will destroy the original
51
interview recordings and field notes to protect study participants’ privacy after three years in

compliance with Colorado Technical University (CTU) guidelines, to include physically

destroying the 256-bit encryption FIPS 140-2 level 3 compliant USB drive after publication of

the study’s results.

Data Analysis

Research data analysis began immediately upon the completion the first few interviews.

Before coding, this investigator uploaded the validated interview transcripts to NVivo 11, a well-

known computer-assisted qualitative data analysis software from QRS International (NVivo,

2016) to help organize and analyze data. To effectively conduct the data analysis from this

exploratory qualitative study, the researcher sought professional coding to guarantee that

participants’ responses were categorized and coded based on the study’s emerging interview

themes (Barbour 2008). Also, two professionally trained doctoral management candidates (or

peers) helped check all study participants’ interview responses were coded appropriately. The

researcher also provided these two peers with explicit instructions (coding manual) while coding

the emerging study themes using NVivo software. Thus, to analyze data for this exploratory

study, the researcher adopted a six-procedure step Creswell (2014, p.197-200) proposed as

follows: (1) organize data, (2) look for the meaning of data, (3) and code all data. Toward this

end, the researcher also (4) developed relevant qualitative themes, (5) represented data in table

and figure formats for visualization, and (6) interpreted finding results of the study section. The

investigator then categorized and coded the data from the interview transcripts using a thematic

analysis (Bryman, 2012; Majdzadeh et al., 2012; and Mitchell et al., 2010). In addition, the

researcher also triangulated the study’s findings after reaching interview saturation to develop

emerging themes that captured study participants’ various views and opinions.

52
 Ethical Considerations

As a researcher with research and development pharmaceutical background, the

investigator understood the value of conducting ethical research. As such, it was imperative to

ensure participant protection during the research project, not only in the pharmaceutical industry

but also in hospitals as well. Given that most hospitals operate in a highly regulated environment,

much like pharmaceutical companies, the researcher followed all federal, state, and local

authority guidance, including that of CTU’s academic Institutional Review Board (IRB). Making

sure participants’ rights were protected helped create trust and confidence between the

participants and the researcher in support of allowing a fair and efficient data collection (Wright

& Senokwane, 2012).

In this study, all potential participating senior hospital executives were volunteers. Thus,

the investigator of this study sought and obtained approval from CTU’s (IRB) committee before

beginning any data collection. Punch (2013) asserted that in many of the investigations,

researchers collected data from volunteers (the people) about people; therefore, they should

expect that ethical issues will arise in the course of any research inquiry. To help participants

make well-informed decision to consent willingly or deny participation in this research inquiry,

the investigator provide informed consent forms that hospital leaders (participants) signed to

express their willingness (or not) to participate. This acceptance form presented the (1) identity

of this investigator and his affiliated academic institution, CTU. It also revealed (2) the purpose

of the study, including its potential risks and benefits and (3) its expected timelines. Finally, the

consent form clarified (4) the possibility of future contact with participants in pursuit of in-depth

EBMgt exploration and its corresponding challenges and benefits through interview conduction.

In this academic research project, the researcher collected neither clinical medical records

nor patients’ data from any participating healthcare practice (hospital). Instead, this study
53
collected and used anonymized self-reported data (interviews) obtained from senior hospital

leaders on their attitudes or perceptions EBMgt use and approaches within their organizations.

The researcher also included copies of his (a) professional resume and (b) IRB approval from

CTU to ensure participants understood that he was knowledgeable of the code of ethics

concerning their professional associations (American College of Healthcare Executives and

CHA) of which he is also a member. By so doing, this researcher wanted to guarantee the

protection of the participant’s individual rights to gain their trust and build their confidence in

the investigator’s credibility. With such confidence, this researcher ensured participants that their

information shared during interviews would be kept confidential. In so doing, this researcher

guaranteed that participants’ professional and human rights, including their dignity, would not be

compromised or violated in any way. This researcher also ensured that the IRB ethics training

with Collaborative Institute Training Initiative (CITI) was up-to-date to allow conduction of this

research endeavor involving human subjects.

Summary of Chapter Three

Chapter Three discussed the research methodology applied to collect and analyze data.

Toward this end, it addressed issues such as the research traditions, the targeted population, and

sampling procedures used in support of generating credible research, to include awareness of

ethical concerns. This chapter also presented the instrumentation used and discussed its validity

and reliability, including data collection and corresponding data analysis methods.

This research inquiry aimed, as previously indicated, to explore hospital leaders’

perceptions of knowledge and attitudes toward the linking of EBMgt and EBM in healthcare

organizations and to explore the readiness of these entities concerning the implementation of

such integration. It also aimed to explore the perceived influence of EBM integration and EBMgt

on hospital performance, as well as the contextual factors that affect senior hospital leader
54
decision-making processes. With this study, this researcher intended to unravel the contributions

and benefits that such integration may offer hospitals in the Denver Metropolitan area in support

of a culture of evidence-based practices with their institutions. The findings of this exploratory

qualitative study can help identify new research opportunities needed to advance EBMgt

application in healthcare settings.

The researcher proposed that understanding the features and dynamics of EBMgt culture

may help understand and explore the possibilities of transferring EBMgt and EBM practices

from one healthcare institution to another. Shortell et al. (2007) maintained that less than 45% of

the U.S. patients receive care that is not based on EBM practices. Thus, ensuring that hospitals

successfully integrate EBM and EBMgt practices can increase the population of patients who

receive 21st-century medical interventions.

Such investigation may also help managers and executives in hospitals realize the

relationship between EBMgt and the performance of an organization and how this relationship

might aid in creating a culture of EBMgt that can benefit patients, employees, as well as the

whole healthcare institution. Integrating EBM and EBMgt practices might also create a

significant competitive edge for the healthcare institutions. The results of an empirical study that

integrates EBM and EBMgt may yield useful information for hospital policy makers to make

informed decisions based on the best professional practices that arise from the use of both EBM

and EBMgt in hospitals (Guo, 2015).

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 CHAPTER FOUR

The overall research question for this study was: What can be learned from senior

hospital executives and health systems in the Denver metropolitan area about how to

systematically implement EBM-EBMgt? The investigation aimed to understand how senior

executive leaders and managers perceive, understand, and use EBMgt and its integration with

EBM to improve the quality of care and institutional performance. Thus, the study explored

perceptions and understanding of healthcare executives about the perceived influence of EBMgt

and EBM integration on strategic management, operations, and hospital and health system

performance. To answer the central research question, the researcher undertook an exploratory

qualitative study to gain deeper and richer insights from senior healthcare leaders concerning

their perception of EBMgt and EBMgt-EBM integration. Chapter Four of this qualitative

exploratory study comprises five sections: 1) pilot study and setting, 2) participants’

demographics, 3) presentation of research data (study variables), 4) presentation and discussion

of findings, and 5) summary of this chapter. It also includes a transition to Chapter Five.

Pilot Study and Research Setting

Pilot Study

As indicated in Chapter Three, subject matter experts—scholars who possessed many

years of real-world and research experience in healthcare organization management and

leadership—checked and validated the protocol interview questions. The researcher used the

validation process for qualitative research designs that Prescott (2011) has proposed. The process

consisted in (a) analyzing the literature, (b) self-reflection and self-interviewing, conducting (c)

semi-structured interviews with health management experts and the targeted population of

hospital executives, (d) obtaining feedback to clarify interview questions, and (e) conducting the

pilot study. Based on the observations and recommendations of these scholars, the research

56
interview questions were rearranged to capture the leadership job titles (or positions) and

responsibilities of participants; their familiarity and understanding, including practical examples

to the extent of EBMgt use; and perceptions on systematic integration of EBM-EBMgt in their

healthcare organizations, respectively. The rearrangement of the study protocol interview

questions resulted in clarity and flow of the research interview questions, thus, guaranteeing they

were explicit and effective to yield deeper and richer responses from the study participants as the

researcher intended (Maxwell, 2006).

Research Setting

Hospitals and healthcare systems of the Denver Metropolitan area, award-winners of at

least one of the high and prestigious three institutions previously indicated, constituted the

study’s context. The Denver Metro area (Appendix D) includes seven counties: (1) Adams, (2)

Arapahoe, (3) Boulder, (4) Broomfield, (5) Denver, (6) Douglas, and (7) Jefferson. However, for

this study, the areas was extended to encompass two additional counties, Larimer and Weld, as

reported by the Metro Denver Economic Development Corporation (January 21, 2016) since

health systems under study had hospitals in these two counties. Several standalone hospitals and

healthcare systems provide healthcare to the population of the region mentioned above

(Appendix D). Thirteen (13) senior healthcare leaders in four major health systems in the Denver

Metropolitan area participated in the study. For participant confidentiality, the researcher did not

provide the names of these healthcare institutions or the participants in this report.

Participant Demographics

The research sample consisted of 13 senior executives of hospitals and health systems

within the Denver, Colorado, area. Eleven of the study participants were Fellows, and two were

members of the American College of Healthcare Executives (ACHE). All of the study

participants had at least two or more years of experience in hospital management and healthcare

57
leadership. Among the study respondents were chief executive officers (CEOs), vice-presidents

(VPs), and chief administrative officers, such as chief nursing officers, chief operation officers,

and chief financial officers. Senior executive directors of hospitals and health systems were also

included as participants in this research project. Some research participants had cumulative

responsibilities; for example, president/CEO and VP/chief nursing officer of for-profit or not-for-

profit organizations.

Table 1 illustrates the distribution of participants by gender and leadership positions who

shared their perceptions about their personal and organizational experiences using EBMgt

practices. Participants included 8 males (62%) and 5 females (38%). Based on the healthcare

leadership positions held, 8 of the participants were CEOs and VPs while the other 5 remaining

respondents included senior executive administrators and directors. All CEOs were males, and

all VPs were females but one. Descriptive information about participants, identification numbers,

and individual attributes (job title, gender, management experience, and education), including

interview dates, are presented in Appendix E.

58
Table 1. Distribution of Participants by Gender and Job Titles or Positions

Attributes Response frequency

Female 5

Gender Male 8

Total 13

CEOs 4

VPs 4

Title/Position CAOs 2

SEDs 3

Total 13

In Table 2, healthcare management and leadership work experiences of the 13 senior

executive leaders ranged from 2 years to 10 years. Seven of the participants had at least 5 years

of healthcare professional experience. Each of the other 6 senior healthcare decision-makers (or

officials) had less than 5 years of hospital administration or management experience. However,

al1 13 participants met the study inclusion criteria as indicated in Chapter 3.

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Table 2. Participants’ Management and Leadership Experiences

Years of Experience Response frequency

≥ 2 years 2

3-5 Years 4

5- 9 Years 5

≥ 10 Years 2

Total 13

All 13 study participants completed post-graduate educational levels of master’s and

doctoral degrees, in various healthcare management and business administration disciplines, as

presented in Table 3.

Table 3. Demographic Profile of Participants’ Education

Education Field of Study Response frequency

Business Administration 4

Master’s Healthcare Administration 4

Management & OD* 2

Total 10

Leadership & OD* 1

Doctorate Business Administration 1

Healthcare Management 1

Total 3

*OD: Organization Development

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 Ten of the interviewed senior hospital executives possessed master’s degrees, which

included four in Business Administration, four in Healthcare Administration, and two in

Management and Organization Development areas, respectively. At the doctoral level, the 3

remaining research respondents possessed a doctorate in each of the field studies mentioned

herein.

Presentation of the Data

The presentation of data identifies the various emerging categories and themes resulting

from the qualitative data analysis from the participants’ interview responses. For a concise, clear,

and accurate representation of the interviewee ideas and statements, and to further guarantee

their anonymity, the researcher edited respondents’ quotes to ensure they were grammatically

correct and understandable. Consequently, the investigator made sure that quote editing

faithfully represented the participants’ original statements or ideas as included in the interview

transcripts.

Based on the study’s semi-structured and open-ended interview questions, which derived

from the literature review, participant responses generated an enormous amount of data that were

professionally coded using Nvivo Pro 11 software automation processes. The researcher

organized, using NVivo, participants’ interview responses into into10 “parent coding nodes or

reports,” with each being a category comprising subcategories (Saldaña, 2015):

1. Position and responsibilities

2. Concepts of EBM, EBMgt, and the integration EBM-EBMgt

3. Strategic role of EBMgt

4. Examples of EBMgt

5. Extent use of EBMgt in personal and organization management practices

6. Role in providing better care

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 7. Influence on senior leaders’ practices

8. Embrace of change by CEOs and other senior leaders

9. Current strategic processes

10. Contextual factors, barriers, and champions

The details of the 10 coding reports obtained from NVivo Pro 11 software application are

provided in Appendix C. Using a thematic analysis of participants’ responses, themes were

extracted from these categories to address the study’s overall research question: What can be

learned from senior hospital executives and health systems in the Denver metropolitan area about

how to systematically implement EBM-EBMgt? Hence, the presentation of participants’

responses (data) has been organized according to the categories previously identified, which

were also used to develop study themes. The development of categories was necessary to inform

readers of the various participant responses shared regarding their experiences and perceptions of

EBMgt and integration with EBM in healthcare settings. These categories, which were the first

higher order of abstraction of participants’ responses (Vaismoradi et al. 2016), represented their

accounts before an implicit development of studying emerging themes.

Position Responsibilities

The first category included the 13 senior healthcare executives’ accounts about their

positions and responsibilities in healthcare management and leadership. One of the respondents,

a VP, indicated he was responsible for service-line quality for six hospitals in one of the major

health systems in the Denver metro area (RP3). Another participant, a CEO, noted, “I am

ultimately responsible for all operational management activities that happen in the hospital”

(RP9). Another one, a management financial officer, reported that his responsibilities included

overseeing financial and business aspects of his organization (RP8). As for RP6, his job entailed

managing pharmacy operations, including supply chain initiatives and cost management. In her
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hospital system, RP2 indicated she was responsible for hospital IRBs, research operations,

contracting, operational grants, as well as community health and values integration. Participants

in this study held top management positions that significantly impacted their organization’s

strategic decisions.

Concepts: EBMgt and EBMgt-EBM Integration

The second parent node included responses on the familiarity of participants with three

concepts. All 13 participants were familiar with both concepts of EBMgt and EBM, and they

provided personal and practical definitions of each concept. Twelve of the study respondents also

offered the perceptions about their understanding of the concept or idea of integrating EBMgt in

hospitals that practice EBM as presented in Table 4.

Table 4. Concept Understanding

Concepts Response frequency

Evidence-based medicine (EBM) 13

Evidence-based management (EBMgt) 13

Integration of EBM & EBMgt 12

Regarding EBMgt and EBM integration in hospitals and health systems of the Denver

metro area, one of the respondents (RP8) described it as “the best of both worlds, honestly; that

is kind of where all healthcare organizations should be trying to get to.” Another participant

viewed the integration as a means of providing a health organization environment where

physician leaders and administrative executives of the organization work together, in partnership,

to utilize these two evidence-based research principles to make effective strategic management

decisions (RP10).

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Strategic Role of EBMgt in Strategic Decision Making

The strategic role of EBMgt constituted the third “parent coding report.” In providing

their perceptions regarding the roles EBMgt and EBM integration might play in healthcare

organizational strategic decision-making, all 13 study participants responded that this integration

would exhibit a positive contribution. “I think that would be considerably beneficial,” as RP7

indicated. One respondent maintained that integrating the two would significantly contribute to

how senior executives gather the needed evidence and essential data and facts to make major

strategic decisions addressing organizational management and leadership issues effectively

(RP9). RP11 noted that this integration would ensure that hospitals provide senior leaders with

quick and easy access to reliable and sound empirical data upon which to drive organization

tactical decisions.

Examples of EBMgt

Participants were asked to provide examples in three areas of their organizations to

illustrate how senior executives utilize (or make sense of) the information derived from EBMgt

(management side) and EBM (clinical side) to make strategic decisions in healthcare

organizations. Table 5 identifies the frequency of the interviewees’ responses of the fourth

category.

Table 5. Typical Example Areas of Use of EBMgt

Strategic Area Response frequency

Operational management 12

Strategic management 11

Core business transactions 6

Hospital construction 1

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 Based on the number of responses, study participants perceived operational and strategic

management as being the most critical areas, with 11 and 12 responses noted respectively.

Regarding operation management, one of the study respondents indicated that his hospital uses a

popular strategic planning software as a tool to help the organization keep track of all strategic

planning activities for the past recent years (RP10). For example, according to another

participant (RP8), a financial executive from the same institution, noted the health organization

had a systematic process that helps the senior leadership team capture how the organization is

performing in terms of (a) patient experience, (b) financial vitality, (c) growth, (d) community,

and (e) research and education: “In each of our strategic initiatives, there is a senior leader in

charge to report, using metrics, how the organization operational units are performing (RP8). By

leveraging strategic scorecards from the health system, RP8 noted that the executive

management team could review all strategic initiatives that tie in the hospital’s operational or

tactical actions.

According to respondent RP10, a CEO with five years of healthcare leadership

experience, his hospital has been using evidence (information) derived from EBM and EBMgt

practices to identify opportunities and problems with patient flow. One decision-maker indicated

that patient flow was excellent because so many variables were involved (RP13) while

participant RP10 noted that patient flow is enormous and requires both the organization’s clinical

leadership and operations on the management side to agree on how patient flow throughout the

organization should occur. Participant RP10 noted, “There are so many variables involved in that

EBMgt, combined with EBM, could play a significant role to improve hospital admission

capacity and patient satisfaction.”

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 Eleven of the interviewed senior leaders of hospitals and health systems offered their

perceptions regarding the use of EBMgt, and its combination with EBM, in the area of strategic

management. Expanding a healthcare organization capacity was given as one example that

applied to the strategic management area as noted by participant RP2: “If building a new unit to

expand our service lines, we have an ingrained process that we go about when making a strategic

evaluation of our decisions.” RP2 also stated that the creation of dyad leadership teams, a

partnering between a physician leader and an administrator, was as a good example in her

hospital that requires the application of EBMgt-EBM integration since these dyad teams impact

hospital operational management. According to RP3, EBMgt-EBM was essential to identifying

and matching the strengths and weaknesses of employees with key strategic hospital positions.

RP13 added thought that “the EBMgt-EBM integration could serve as a strategic collaborative

approach between management and physicians on improving patient safety and quality outcomes

at a health institution.”

Among the provided examples in the area of hospital core business transactions, one

stood out above the others. According to RP7, at her organization, another major health system

in the Denver Metropolitan area, senior hospital executives use research evidence from both of

these concepts when making major capital decisions. One senior executive director indicated that

her organization had adopted evidence-based management approaches when dealing with

mergers, acquisitions, and joint ventures to help the leadership ensure its sustainability and

growth (RP7). In another hospital, RP12 provided the example of management of the medical

records; he highlighted the medical record since it had critical impacts on both the management

side of the business and the medical services side of hospitals.

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Extent Concerning Current Use of EBMgt

The extent of current EBMgt use was another important data coding category. The

researcher asked senior hospital managers an interview question, including sub-questions,

regarding the extent of their personal and organizational use of EBMgt. This interview question

also included the impact of EBMgt on management and leadership styles of executives. In this

regard, the participants’ responses were organized into four subcategories: (a) 11 on

organizational management practices, (b) 10 on personal managerial practices, (c) 12 on effects

on personal management styles, and (c) 10 on the impact on other seniors’ leadership styles as

shown in Table 6.

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Table 6. Extent of EBMgt Use

Category Sub-Category Response frequency

12 of 13

50-60% 2

85-90% 2

Organizational management practices Mixed results 3

Most or all the time 4

Not very well 1

10 of 13

50% 1

70% 1

Personal managerial practices 85-90% 2

Situational 5

Tremendous Impact 1

12 of 13

No effect 2

Personalize style 1

Effects on management styles Positive impact 4

Situational 5

12 of 13

80% 2

Impact on other Senior Leaders Styles Most or all of them 6

Situational 4

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 Organizational management practices. As for the use of EBMgt by healthcare

organizations, senior hospital leaders provided various accounts. One participant stated her

health setting used about 50%. In another hospital, an executive administrator, stated the CEO

was highly engaged in EBMgt practices, and his organization considerably valued available

research evidence and the staff professional experience to make profound organization decisions

(RP8). He explained that his hospital was using 85-90% EBMgt approaches when making

strategic decisions. Based on participants’ answers, there were healthcare organizations that

practiced 50-60% and, 85-90% of EBMgt, and those that used EBMgt practices most of the time

in making major strategic decisions. In other hospitals and health systems, participants reported

mixed feeling about EBMgt practices. One senior executive remarked she could not tell where

her organization was on a 1–100% scale, but she certainly had high hopes; she declared there

was a lot of agreement among senior leaders that the health institution will get there (RP6).

Personal management practices. Regarding the use of EBMgt at the individual level,

there was also a variation in participants’ responses. For instance, one participant (RP6) stated

she was in the 50-60% range whereas another respondent (RP1) believed her use of EBMgt was

at about 70%. RP1 explained that she stops to think about what the evidence shows and what it

means in the context of her organization. According to an executive director (RP7), her use of

EBMgt was around 90%, and that was because she understands a gap exists between

management research and practices of healthcare communities stating the following: “I see many

of our organization efforts as being anecdotal.” Some other participants have indicated only

using EBMgt on a situational basis depending on the type of the decisions and the availability of

evidence. These executives noted evidence was not always available or accessible. They would

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only consider using evidence-based principles for the decisions that involved investing strategic

resources (RP9, RP12).

EBMgt effects on management styles and other senior executives. Senior executives

of hospitals and healthcare systems perceived different impacts that EBMgt practices had on

their administration and leadership styles, including that of other top leaders’ in the organization.

One CEO thought EBMgt had no effect on management style (RP11). RP11 explained that a

leader’s behavior was driven by his or her values and the organization’s mission. He stated that

hospital senior managers’ behavior and leadership approaches were powered by the root of their

personal and professional values, including the values of the organization. Thus, they should not

behave any differently because of the practice of EBMgt.

In contrast to participant RP11’s observations, RP6 thought EBMgt had a tremendous

impact on his management style, given that he received EBMgt training and coaching from one

renowned EBMgt author, David J. Fine. As a co-author, Fine, Kovner, and D’Aquila published

the book Evidence-Based Management in Healthcare (Kovner, Fine, D’Aquila, 2014). RP6

maintained that having worked with Dr. Fine in the same health institution had significantly

impacted his understanding of EBMgt principles. According to another senior leader (RP8),

practicing EBMgt gives one credibility to which peers can reflect and observe the evidence used

to support decisions. He explained that EBMgt could prove or show how one uses the literature

to support thought processes. He declared, “I think it lends credence to your decision-making

thinking process and outcomes; it gives you much credibility across the organization” (RP8).

As observed with personal management practices, 5 healthcare executives viewed their

management style as situational. Overall, 6 participants reported that, depending on the situation,

EBMgt had a positive impact on their personal managerial practices, including their colleagues’

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leadership styles while 4 hospital leaders thought the impact was only situational. These results

showed that the extent of EBMgt use varied depending on senior leaders’ management and

leadership styles. Although some organizations were open to practicing EBMgt, others were still

questioning its value.

Role of EBMgt-EBM in Providing Better Care

The sixth coding report contained responses about the role of EBMgt-EBM. Research

participants were also asked the question about the perception of their health care institutions in

linking EBMgt and EBM practices to provide better care. The researcher also probed them about

the perceived role EBMgt-EBM integration might play in developing an evidence-based,

decision-making culture in a healthcare setting. Interview responses revealed that 9 (69%)

participants thought it yielded evidence-based outcomes, 8 (62%) highlighted it improved

competency and skills, 6 (46%) indicated staff empowerment, and 5 (38%) reported training and

senior managers leading by example, as presented in Table 7.

Table 7. Participants’ Perception of EBMgt-EBM Role

Role of EBMgt Response frequency

EB outcomes 9

Competency & skills 8

Staff empowerment 6

Training 5

Lead by example 5

Regarding outcomes, participant RP9 stated that just as one would expect with EBM,

hospitals following evidence-based leadership practices (EBMgt) would have a better,

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repeatable, evidence-based outcome. Participant RP7 noted that health systems that embrace

management theories could have better results if they apply both concepts of EBMgt and EBM.

However, on the issue of competency and skills, another executive responded that if hospitals

embraced EBMgt, senior managers would be promoting people who have the skills and ability to

perform evidence-based practices rather than promoting individuals who happen to be the best

nurses or the best doctors (RP1). By so doing, participant RP1 thought it would complete change

everything about how care was provided to patients and communities. Healthcare providers

would have high functioning leadership teams where there was good collaboration and trust

between hospital management and operations and the medical clinical group to foster a culture of

accountability and transparency (RP6). As for staff empowerment, participant RP13 felt that

EBMgt-EBM integration might create a greater partnership needed between hospital

management and clinical leadership to provide high-quality, evidence-based, care to patients.

Also, participant RP13 indicated that EBMgt-EBM integration would result in more

collaborative efforts to integrate and align physicians and the medical staff with the institution’s

strategic goals.

Some interviewees indicated that combining EBMgt and EBM practices could also help

improve training and patient satisfaction, including how the organization compares to other

hospitals or competing benchmarks with setting a leading example for other institutions in the

metro Denver area. For example, according to participant RP13, as an executive responsible for

outcome measurements in his health system, he tracks several dimensions to monitor hospital

performance. Among many performance criteria, he cited financial results, senior leadership

engagement, human resource indicators such as turnover rates, and other indicators. RP10 also

72
agreed that his organization measured different metrics such as finances, employee turnover,

employee engagement, productivity, and so on.

Influence on Senior Leaders’ Practices and Organization Performance

The seventh data coding report contained participants’ views about the influence of

EBMgt-EBM integration on senior leader management practices. All 13 participants stated it

would have a significant impact. Most respondents agreed it positively impacts accountability

and transparency: 10 reported it created supportive relationships, and nine thought it positively

impacted organizational performance, as shown in Table 8.

Table 8. Influence of EBMgt on Senior Leaders

EBMgt-EBM Influence Response frequency

Accountability 13

Transparency 13

Supportive relationships 10

Organizational performance 9

Training & Education 6

Lead by example 5

One participant asserted that if senior executives of hospitals or health systems integrate

EBMgt into their management and leadership practices, they will be transparent and hold people

accountable. He shared that “if you do not hold anyone accountable, you will have maybe 60%

of the work that gets done” (RP8). Another senior leader (RP12) thought there was a positive

influence on accountability and transparency because when hospitals integrate management

executive and medical leadership teams, they create an environment that increases

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communication amongst those teams. As a part of that, hospital executives are almost

automatically creating transparency because they are giving the staff the opportunity to regularly

communicate and share expertise on the various projects they had initiated. By so doing, the

organization staff develops supportive relationships that contribute to improving hospital

performance. Participant RP7 stipulated that with accountability and transparency, executives are

compelled to develop relationships to support the staff better and provide them with the needed

resources. As previously noted, research participants included training and education with senior

decision-makers and the organization leading by example as two other areas in which combining

EBMgt and EBM might positively impact the quality of care.

Impact on CEOs/ Senior Leaders toward Embracing EBMgt

The eighth coding report included responses from participants related to their perceptions

of EBMgt-EBM integration influence toward healthcare CEOs and other senior leaders as

presented in Table 9. Out of 13 research participants, 9 thought EBMgt-EBM practice would

influence or change a CEO’s and senior leadership team attitudes and 7 mentioned improving

awareness and buy-ins toward embracing EBMgt practices. According to participant RP10, a

CEO can be influenced by it and by other leaders, especially his or her direct reports: “When my

boss, a CEO, who is just very much driven by excellence and very influential in the organization

finds something that works from one of his senior leaders, he will embrace it and promote it

within the organization.”

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Table 9. Influence on CEOs and Senior Leaders

Sub-categories Response frequency

CEO Influence 9

Awareness-Buy-Ins 7

Systemic control 5

One healthcare executive stated that EBMgt-EBM integration needed to be called out and

thought that all health professionals, including senior leaders, take it for granted and assume it is

happening in their organizations (RP8). From participant RP8’s perspective, he believed that

hospital executives were not cognizant of it: “I think there just needs to be some awareness of

EBMgt-EBMgt integration; I think maybe your study and some other literature reviews if they

were published, would help with that awareness.” This hospital decision-maker thought

increasing the awareness to EBMgt also requires healthcare organizations to dedicate more

resources to it. Participant RP8 was also convinced that if CEOs and senior managers saw

EBMgt-EBM integration in practice, before and after the combination of these two concepts,

they would be astounded. He thought no better understanding exists concerning the full power of

integration between both of these principles.

One healthcare executive stated that the integration of EBMgt-EBM needed to be called

out and thought that all health professionals, including senior leaders, take it for granted and

assume it is happening in their organizations (RP8). From participant RP8’s perspective, he

believed that hospital executives were not cognizant of it stating, “I think there just needs to be

some awareness of EBMgt-EBMgt integration; I think maybe your study and some other

literature reviews if they were published, would help with that awareness” (RP8). This hospital

75
decision-maker thought increasing the awareness to EBMgt also requires healthcare

organizations to dedicate more resources to it. Participant RP8 was also convinced that if CEOs

and senior managers saw the integration of EBMgt-EBM in practice and saw the before and after

the combination of these two concepts, they would be astounded. He thought there was no better

understanding of the full power of integration of both of these principles.

Among other themes, 5 participants included having a systemic control means in place to

ensure compliance at the organization level. For example, participant RP9 indicated that the

compliance might be just 30% because some health practitioners and leaders would not have

adopted EBMgt practices. Also, he stated that it is necessary to get stakeholder buy-in to put

processes in place so the hospital can hard-wire an EBMgt approach.

Current Strategic Management Processes

A second to last coding category encompassed responses on hospitals’ EBMgt

management processes. Twelve of the interviewed hospital executives indicated having current

management processes in place to make strategic decisions at their institutions. In one of the

interview healthcare settings, one research participant (RP7) remarked that strategic management

practice is integral and well-known within the health system, and they do not vary from it,

especially from major operational decisions that would impact the organization (RP7). At

another hospital facility, participant RP13 noted the organization’s core values were used as the

guiding principles for the decision-making process. Most participants stated for major capital

decisions, including mergers and acquisitions, they use their organization’s mission and vision

statements to guide their decision-making. However, study respondents noted a lack of formal

systematic organization of EBMgt processes and infrastructures to promote it.

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Contextual Factors, Barriers, and Champions

The last parent-coding report consisted of three subcategories: (a) contextual factors, (b)

barriers, and (c) EBMgt-champions (facilitators). Participants were asked what they perceived to

be the most important contextual factors for systematic EBMgt-EBM integration to occur in

healthcare, including its potential barriers and facilitators (or champions). Participants identified

several factors as illustrated in Table 10.

Table 10. Most Important Factors

Factors Response frequency

Culture 8

Leadership 7

Awareness 4

Data evaluation 4

Important contextual factors. A hospital’s or health system’s culture and leadership,

including its clinical practice setting constitute the organization’s context, an environment in

which healthcare takes place (Stetler et al., 2009). Leadership and culture are two critical

contextual mediators of evidence-based practices (Rycroft-Malone et al. 2002). Out of the 13

participants and the 11 who provided their perspectives on the most contextual factors, 8 thought

that healthcare organization culture factors were key to integrating EBMgt-EBM facts while 7

indicated that leadership factors were key to integrating EBMgt-EBM. The senior hospital

manager, participant RP1, asserted that leadership and culture were both critical factors as wells

as barriers to the EBMgt-EBM integration process. She explained that, most importantly, culture

gets in the way of both EBMgt and EBM because of the nature of tribal healthcare activities.

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According to this health professional, “Healthcare is terrible about tribes: the doctor tribe, the

nurse tribe, the administrator tribe.”

Participants RP6 and RP5 also agreed with the perspective that culture was the most

important factor because it starts at the top of the executive management team with the most

senior leaders and the CEO. Participant RP5 believed that the executive team had to promote a

culture of learning and a culture of inspiration within the organization to encourage hospital

managers and medical leaders to embrace EBMgt practices. Participant RP1 argued the

following:

“We, healthcare executives, get perturbed that physicians do not use evidence-based

practices. One of the reasons why they do not use EBM practices is because we, senior

hospital leaders, are not doing all of the things that the evidence says executives need to

do to help people and organizations change.”

Participant RP13 stated that the culture of his health organization reflected the way

leaders treat the people in the organization—the way executives act on a daily basis. Toward this

end, participant RP13 added that for EBMgt and EBM to be embraced effectively at all

leadership levels and throughout an institution, executives at the top have to model those

principles.

Among other important factors, participants included senior hospital leaders’ awareness

of evidence-based practices, data evaluation, and organization needs analysis. According to

participant RP11, the healthcare field requires empirical evidence to inform stakeholders about

the impact of certain strategic decisions. He stated that the data, clinical as well as management

data, drive change, and the data help to prove new concepts healthcare organizations should

implement. However, as participant RP2 stated, just having good data is not enough; the data has

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to be accessible and properly evaluated by the organization’s expertise. In this vein, participant

RP11 noted that it takes a commitment from the leadership at the highest level to ensure the data

and facts. The foundation of evidence-based decisions is robust and has credibility. Thus, data

evaluation is necessary because it reveals organizational issues, opportunities, and challenges

that the executive leadership team needs to address. These research participants also detected the

need for resources, training, and organization infrastructure as additional factors that could

facilitate EBMgt-EBM implementation and integration.

Barriers. A subcategory “Barriers” included hospital factors that hamper both the use of

EBMgt and EBMgt-EBM linking. Concerning barriers that prevent EBMgt, EBMgt-EBM

integration into healthcare organizations, 5 participants stated leadership and 4 mentioned the

lack of policies and structures in hospitals. Furthermore, 4 other respondents highlighted the

conflict between the institution’s priorities, including data issues, and the lack of trust to be

additional key barriers as noted in Table 11.

Table 11. Barriers to EBMgt and EBMgt-EBM Integration

Barriers Response frequency

Senior leadership issues 5

Policies and structures not in place 4

Priorities 4

Data issues 3

Lack of trust 3

As previously indicated, study participants regarded both leadership as well as culture as

important contextual factors that facilitated or hampered EBMgt-EBM integration efforts within

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healthcare institutions. Alluding to organization priorities, one senior executive (RP10) explained

that EBMgt-EBM integration does not appear on the list of priorities for hospitals and health

systems, but everything else is listed. Participant RP10 felt that in healthcare there were so many

high-priority issues, whether dealing with the Joint Commission requirements and finances, for

example, constituted challenges for hospital leadership teams. The 13 health decision-makers

who agreed to participate in the study indicated that resistance to change, hierarchy issues,

resistance to authority, including lack of commitment and trust, were among other barriers that

hampered EBMgt integration and its integration in hospital settings.

EBMgt-EBM integration champion personnel or team (facilitators). In discussing the

interview question regarding a responsible champion or party who should coordinate the effort of

systematically integrating EBMgt-EBM in healthcare organizations, participants advanced

various propositions as noted in Table 12.

Table 12. Champions of EBMgt-EBM Integration

Champions Response frequency

Senior leadership 6

CEOs 5

CMOs 3

Other seniors leaders (*) 6

(*) COO, HRO, CNO, CFO

Six respondents pointed that it was the role of the overall hospital leadership. Five

thought a CEO had to be the EBMgt-champion, while 3 others indicated the chief medical officer

was the ideal candidate suited for the facilitator or champion role. According to some study

respondents (RP11, RP6, RP8, and RP12), for example, because a CEO sets the organization’s

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strategic vision, he or she is to champion the EBMgt-EBM integration effort. By so doing, the

CEO can ensure EBMgt becomes part of the decision-making process to generate needed

evidence (information) to support both hospital operational management and the overall strategic

leadership team. As noted by participant RP11, “It starts at the top of the organization with the

chief executive officer.”

Other participants pointed out that a CEO could also delegate the championing

responsibility of EBMgt-EBM integration to other senior leaders such as the chief medical

officer, the chief operations officer, and the chief nursing officer, and even to a third party or

consultant (RP6, RP11, RP13). All participants stated that the CEO (or president, depending on

the structure of the institution), had to set the tone at the top level of the organization. According

to RP13, the COO, human resource organization, and probably the CFO had to be involved and

engaged in the EBMgt leadership team since they probably have more operational insights about

organizations than they used to in past decades. He thought these three types of chief

administration officers were indispensable in allocating needed resources efficiently and

accordingly. One health decision-maker noted that if the CFOs understand EBMgt-EBM

integration, they can better shape how resources are allocated (RP8). Concerning the choice of

the hospital EBMgt-champion, participant RP6 suggested that a third-party person should be

hired at the senior leadership level which has access to the hospital board and is not afraid to

speak the truth to the people of “super power and influence.” One of the participants also

indicated that non-traditional leaders, those out of the C-suite leadership team, could be an

EBMgt-EBM organization integration champion.

Presentation and Discussion of Findings

This research investigation focused on extracting emerging themes from senior healthcare

executive participants to learn their perceptions of EBMgt implementation and integration with
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EBM in hospitals and health systems of the Denver Metropolitan area. Using the NVivo Pro 11

software, the investigator conducted thematic and content analysis to organize the respondents’

transcribed data to extract relevant process codes. This analysis led to developing 10 categories,

including subcategories, which were presented earlier. These study categories, which represented

the content of the senior healthcare executives’ accounts, were used to develop themes that

related to the literature review and addressed the overall research question of the study. Based on

interview responses of healthcare leaders, the researcher organized the study findings into 5

major subject themes as presented in Table 13.

Emerging Themes

The participants in this study, senior leaders of hospitals and health systems in the

Denver Metropolitan area, provided rich details relating to the overall research question and the

supportive interview questions. Thus, five major emerging themes, as shown in Table 13, were

developed to address the research question. The major themes were (1) conceptualization and

understanding of concepts of EBMgt and EBMgt-EBM integration; (2) the perceived impact and

(3) most critical contextual factors, including barriers, and (4) champions of EBMgt-EBM

integration in healthcare organizations. The last detected major theme was (5) a systematic

integration of EBMgt-EBM in hospitals and health systems.

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Table 13. Study’s Major Themes

Theme Subject Themes

Theme # 1 Conceptualization and understanding of concepts

Theme # 2 Perceived Impact of EBMgt-EBM integration

Theme # 3 Perceived important factors and barriers

Theme # 4 EBMgt Senior leadership team

Theme # 5 Systematic EBMgt and EBMgt-EBM integration

Theme 1: Conceptualization and Understanding of Concepts

The first emerging major theme consisted of the conceptualization and understanding of

EBMgt and EBMgt-EBM concepts. In this study, all 13 senior healthcare participants were

familiar with the concept of EBM, and they provided an understanding of EBMgt as an approach

that was rooted in the application of EBM principles in hospital management and leadership

functions. This observation is aligned with the results of hospital executives’ familiarity and

engagement with the idea of EBMgt (Guo, 2015). According to Guo (2015), 62% of healthcare

senior officials are both familiar and very familiar with EBMgt while only 9% are still unfamiliar

or very unfamiliar.

As previously indicated in this study, participants unanimously viewed EBMgt as a

scientific approach that entailed making evidence-based decisions from empirical data and

personal experiences. For example, one respondent indicated that EBMgt was “a science of

management; it is about applying research into how senior healthcare leaders manage people and

their organizations (RP7)” The participants’ understanding of the EBMgt concept revolved

around, as another health executive (RP9) noted, “Utilizing proven leadership strategies and

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tactics that are rooted in evidence.” Despite being able to define and understand EBMgt,

participants provided no indication of consistent and systematic use of EBMgt processes at their

organizations. Of all the senior executives, only 2 participants of the same hospital stated that

their institutions had implemented a balanced scorecard approach that requires using dashboards

to provide the senior leadership team with data visualization tools that were essential

organization capabilities for strategic decision-making. RP12 thought EBMgt could bring great

contributions to a healthcare organization because it would help create a multidisciplinary team

of people to solve your organizational big problems; those that significantly impact the entire

hospital business.

Out of 13 senior leaders of hospitals and health systems who participated, 12 stated they

understood the concept or idea of integrating EBMgt and EBM practices. They viewed the

integration of EBMgt and EBM as a means for health institutions to provide an organization

environment where the clinical leaders of the organization and the hospital administration leaders

work in partnership, using research evidence from both EBMgt and EBM principles to provide

reliable and high-quality care to patients and the Denver metro area community. One hospital

leader explained that her organization had implemented dyad teams, where “an administrator

along with a physician leader worked together on strategic decisions to appreciate each other’s

contributions or role” (RP9). The research participants also indicated that EBMgt-EBM

integration could play a significant role in several areas of strategic decisions, with 12 citing

operational management, 11 indicating strategic management, and 6 noting hospital business

transactions.

Theme 2: Perceived Impact of EBMgt and EBMgt-EBM Integration

The perceived impact of EBMgt and EBMgt-EBM constituted the second emerging

theme. Interview responses concerning the extent of EBMgt use affirmed the detection of the
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second major theme: the perceived impact of EBM-EBM integration. Interviewed healthcare

executives expressed their perceptions about the influence of EBMgt-EBM integration on (1)

senior leaders’ management practices, (2) healthcare organization performance, and (3) its

overall influence on providing better or evidence-based healthcare.

Impact on senior executive management practices. Regarding the use of EBMgt at the

individual level, there was a variation in participants providing different responses. Out of 10

participants who discussed EBMgt use in their managerial practices, the study results showed

that only 3 senior hospital managers and leaders used EBMgt at the level above 70% (on 1-100%

scale). One was ranked in the 70%, and 2 reported using as much as 85-90%. A fourth

participant indicated being in the 50% range. According to the above four respondents, EBMgt

had positively impacted their management practices as well as leadership styles. Research

participant RP6 maintained EBMgt had a tremendous impact on his management style because

he had the opportunity to work and be coached with a prolific EBMgt scholar and practitioner.

“Having had a mentor who published several articles and books on the topic of EBMgt books has

taught me a lot about EBMgt,” RP6 stated. The remaining of the management executives

interviewed in the study stated they use EBMgt occasionally on a situational basis.

Consequently, according to these research respondents, the impact of EBMgt was also

situational. One participant explained that EBMgt helped her personalize her management

toward each of the individual direct reports whereas just 2 others noted that EBMgt use had no

impact on a leader’s management style.

Despite the familiarity with the concept of EBMgt, the study results demonstrated that the

idea of EBMgt was still not widely embraced in healthcare organizations such as hospitals.

Denis, Lomas, and Stipich (2008) indicated that these institutions lacked organizational

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structures or processes to facilitate the uptake of approaches such as EBMgt. Most hospitals also

lack EBMgt-champions, power-users with the necessary skills to include EBMgt practices in the

organization’s “ongoing change management activities” (Denis et al., 2008). Thus, there is still a

growing need for further studies, not just only on the utilization of EBMgt within the context of

healthcare organizations as Cummings et al. (2010) indicated but also on the integration of

EBMgt and EBM (Shortell et al., 2007).

Impact on the performance of healthcare organizations. The interview question

concerning the extent of EBMgt use at the healthcare organization level yielded 11 participant

responses. The result from participants’ responses regarding the use of EBMgt by healthcare

institutions mirrored those of its use at the individual level by senior executives. Just like with

senior management, responses were grouped into three tiers. In the first level, 2 participants

indicated that their hospitals practiced EBMgt in the range of 50-60% (1-100% scale) while 2

other respondents indicated their institutions were in the 85-90% level. In one of the hospitals, an

interviewee stated the CEO was so considerably engaged in EBMgt practices that the

organization, nowadays, values available management research evidence and the staff experience

when making profound organization decisions (RP8). In the second tier, which included 7

leaders, 3 maintained that the practice of EBMgt had mixed results in their hospitals whereas 4

others thought executive leaders used EBMgt practices all the time. In the last tier, 1 participant

asserted that healthcare organizations did not widely use EBMgt.

Based on the participants’ answers, despite the small size of 13 participants in the sample

study, the results showed that there were variations in the way hospitals use EBMgt in the

Denver area. Notwithstanding this variation, 9 participants recognized that EBMgt integration in

hospitals and health systems practicing EBM would impact their performance significantly. All

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13 participants unanimously agreed that EBMgt-EBM integration would also positively

influence the accountability and transparency of the senior leaders’ decision-making process. Out

the 13 participants who provided responses concerning accountability and transparency, 10

reported that EBMgt would yield supportive relationships that were vital to improving hospital

performance.

Impact on providing evidenced-based healthcare. Impact on providing evidenced-

based healthcare. As for participants’ perception of the role of linking (combining) EBMgt and

EBM practices to provide high-quality care, hospital administrators stated that it would foster the

development of a culture of evidence-based decision-making in healthcare settings. This result

corroborated with the study’s conceptual framework that highlights the need for a better

understanding of the context (EBMgt), content (EBM), including processes by senior executives,

as Anderson et al. (2011) suggested, for hospitals to reliably provide evidence-based care to

patients. Nine out 13 respondents thought EBMgt-EBM integration would yield evidence-based

outcomes, 8 it would improve EBMgt competencies and skills of leaders. Among other cited

contributions, 6 health executives declared EBMgt would result in staff empowerment, and 5

others reported that EBMgt, or EBMgt-EBM integration, would encourage senior managers to

seek appropriate training so they can lead effectively.

The participants’ responses were in alignment with the study’s conceptual framework.

Executive leaders of healthcare organizations need to embrace not only EBMgt but also integrate

EBMgt and EBM practices. By so doing, hospitals would gain a better understanding of the

required context, content, and processes needed to building a culture and organizational capacity

that promotes the use of evidence (EBMgt) to deliver quality evidenced-based healthcare

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(Sullivan, Orchard, Umoquit, 2011). For this reason, hospitals and health systems must have

effective leadership and EBMgt processes in place.

Theme 3: Factors and Barriers of EBMgt, and EBMgt-EBM Integration

The third major theme emerged from the 13 healthcare senior leaders’ responses

concerning interview questions about factors, barriers, and facilitators concerning EBMgt-EBM

integration. From a contextual standpoint, there were two primary factors that participants

pointed out as essential to integrating EBMgt and EBM in healthcare organizations: (a)

organization culture and (b) leadership. From senior executive responses, this study showed that

of the 13 participants, 11 provided their perspectives on the most contextual factors with 8 noting

healthcare organization culture and 7 indicating leadership were the key factors to integrating

EBMgt-EBM. Among numerous cited other factors—infrastructure, resources, quality of data—

culture and leadership were the most critical ones to promoting an integration of EBMgt into

hospitals and health systems that practice EBM in the Denver Metropolitan area. These findings

were consistent with those reported by Rundall et al. (2009).

Senior executives who participated in the study also perceived supportive relationships in

hospitals and health systems, training and education of leaders, and the existence of EBMgt

facilitators or champions to be other important factors to incorporating EBMgt into healthcare

organizations. Concerning barriers that hampered or prohibited healthcare organizations from

adopting and implementing EBMgt, EBMgt-EBM integration, hospital decision-makers

identified leadership and organizational culture as the fundamental contextual obstacles. Among

other factors, hospital executives included a lack of defined processes and structures, the conflict

between the institution’s high-strategic priorities, including data issues and lack of trust. One of

the chief operations officers indicated that EBMgt-EBM was not a high priority for most

hospitals and health systems.

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Theme 4: EBMgt Senior Leadership Team or EBMgt Champion

The fourth emerging major theme involved the perceived role of a hospital EBMgt-

champion leadership team. From the discussion with health system managers and leaders,

another important study theme that emerged was the issue of hospitals having an EBMgt senior

leadership team made of EBMgt champions or responsible parties to facilitate or coordinate the

organizational effort to systematically embrace EBMgt. Some study respondents stated that such

a role was to be played by CEOs and CMOs while others indicated that a CEO could delegate a

role of an EBMgt-champion to hospital insiders as other senior leaders or outsiders such as

consultants. Overall, participants highlighted the significance for healthcare organizations

regarding an EBMgt team to help develop and implement an institutional environment where

there is accountability in using EBMgt practices.

Theme 5: Systematic Integration of EBMgt-EBM in Hospitals and Health Systems

Finally, in light of all the interviews the researcher conducted with the participants, a

salient major theme emerged: a need for hospitals and health systems to systematically build the

culture and capacity to promote and practice EBMgt as well as integrate EBMgt-EBM in support

of providing evidence-based care to the population of the Denver Metropolitan area. For a

systematic embrace of EBMgt to occur, the study respondents detected three minor themes

(subthemes) to support a systematic integration of EBMgt and EBM. The three minor themes

were a need for (a) EBMgt senior leadership team, (b) defined organizational EBMgt process,

and (c) EBMgt corporate culture. These were detected from participants’ responses as presented

in Table 14. Coding for the research study question helped to identify the subthemes and

categories needed to discuss a systematic embrace of EBMgt and EBMgt-EBM integration.

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Table 14. Major Theme 5: Three Minor Themes

Minor themes Categories Response frequency

Accountability & transparency 13

Competent qualified people 13

EBMgt senior leadership team Relationships & trust 13

Play to people strengths & weaknesses 8

Partnering 6

Organizational EBMgt process Defined processes and infrastructures 13

Culture-Ingrained thought process 13

EBMgt Organizational culture Strategic questioning 13

Open to change or improvement 13

Published materials 5

EBMgt senior leadership team. The study participants viewed the existence of an

EBMgt senior leadership team as indispensable in promoting and adopting EBMgt practices. As

participants noted, senior hospital leaders must buy into EBMgt, use it, and model it. Another

hospital decision-maker explained that the best way to accelerate EBMgt implementation and

perhaps its combination with EBM in an organization would be to start at the leadership. As

participant RP1 noted, this would include a small group of executives who understand the

importance of EBMgt in the strategic planning process to align institutional objectives and

operational action plans via making strategic decisions. By so doing, interviewed executives

believed that hospitals and health systems would improve accountability of leaders and

transparency of information at various leadership levels. By promoting the use of EBMgt

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strategies, study respondents also indicated that healthcare organizations would benefit by

attracting, hiring, and retaining competent and qualified employees. Participant RP1 stated the

following:

“If we practiced evidence-based management, we would include our medical staff in

strategic decisions. If we practiced EBMgt, we would be promoting people who have the

skills and ability to do EBMgt rather than promoting individuals who happen to be the

best administrator, the best nurse, or the best doctor. As a result, the leadership team will

be able to maximize the strengths and work on the weaknesses not only of employees but

also of the organization.”

Another consistent theme (100%) emerged from participants’ responses in that if senior

hospital leaders practiced EBMgt, it would foster a development of supportive relationships and

trust between hospital management and the clinical medical leadership. Such relationships were

needed for an efficient conversion of organizational-generated data into actionable evidence-

informed decisions. According to participant RP9, organization decisions that are rooted in

evidence provide support to hospital strategies and tactics.

As for partnership, 6 of the executive participants indicated that it is essential for

hospitals to partner with management consulting organizations and research educational

institutions to help with implementing EBMgt initiatives. Such partners, as RP9 indicated, were

fundamental in providing training on a variety of proven evidence-based leadership approaches

of EBMgt, especially concerning how to engage patients and the medical and administrative

staff, as well as how to interact with other hospital stakeholders. For example, some executives

have introduced and embraced the evidence-based leadership framework to help align hospital

and health system goals (Schuller, Kash, & Gamm, 2015)), behaviors, and processes to yield

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evidence-based outcomes (RP8). By so doing, one hospital CEO stated that “because of our

results and our performance, other individual or standalone hospitals are looking to partner with

us potentially” (RP13).

Organizational EBMgt process. The second minor theme extracted from the interview

responses was the need for healthcare organizations to have defined processes and infrastructures

in place to support EBMgt practices. Thirteen out of 13 (100%) participants highlighted the

significance of supportive organization EBMgt processes and infrastructures. Participants

reported a lack of such structures in their organizations. As one participant mentioned, “I do not

think there is a formal process in place” (RP3). Another respondent thought that if hospitals

have, for big strategic decisions, had well-defined evidence-based leadership process for EBMgt,

it will ensure that leaders were following due-diligence and are accountable for their actions

(RP9). From all responses of participants, it is obvious that healthcare organizations not only

needed to have defined structured EBMgt processes to guarantee repeatable positive outcomes

but also an organization culture that is receptive to EBMgt practices.

EBMgt organizational culture. For the senior leadership team to systematically

implement EBMgt, hospitals and health systems of the Denver metropolitan area must have a

culture of critical thinking thought-processes in place. As shown in Table 14, all 13 participants

overall shared the thought that the development of an EBMgt culture requires hospital decision-

makers to provide an environment where critical thought processes and a culture of strategic

questioning becomes the norm. Consequently, hospitals and health systems must develop an

organization culture that is open to change or improvement. Additionally, 5 participants also

indicated that access to EBMgt published materials was essential to promote and support such

this culture and EBMgt activities. Participants viewed healthcare organization leadership and

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culture as necessary to adopting and implementing EBMgt. According to one senior VP, the

traditional culture of healthcare organizations gets in the way of both EBMgt and EBM because

of its tribalistic nature (RP1). Some participants recognized that there were three common

healthcare tribes: (1) the doctor tribe, (2) the nurse tribe, and (3) the administrator tribe.

Furthermore, some participants also noted the existence of the tribe of health professionals with

doctorate degrees, a tribe of those with master’ degrees, bachelor’s degrees, and so on. One

health system executive stated that it would be a huge cultural change for hospitals to embrace

EBMgt fully. However, one optimistic participant, RP1, stated, “I think hospitals will get there

someday.”

Summary of Chapter Four

According to the conceptual framework of this study, EBM (content of providing care)

and EBMgt (context of providing care) are key components of healthcare organizations that

provide high-quality care (Shortell et al., 2007). Thus, to deliver evidence-based health care to

the communities they serve is an ethical issue for both clinical medical leadership as well

hospital management team (Hofmann, 2010). Hence, it is imperative for senior executives of

hospitals and health systems to understand that not only embracing and implementing EBMgt in

healthcare settings is now more critical than ever before, but developing an organizational

culture that is receptive to both EBMgt and EBM is paramount for building a culture evidenced-

based decision making process (Bell, 2011).

Chapter Four presented the findings of an exploratory, qualitative research investigation

of the perceptions of 13 senior executives about systematic EBMgt implementation and

integration with EBM in hospitals and health systems of the Denver metropolitan area. Despite

the small number of study participants, the interviewed hospital decision-makers provided in-

depth and detailed responses relating to the overall research question. Themes resulting from
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participants’ responses provided new and deeper insights into what standalone hospitals and

health systems of the Denver area need to have in place that can ensure adoption and

implementation of EBMgt and EBMgt-EBM integration. Although, most senior leaders

maintained that, individually, they were familiar with EBMgt and used it for strategic decisions,

they also indicated their institutions have not widely embraced EBMgt practices at the

organizational level. Twelve out 13 perceived that EBMgt-EBM integration was critical for

hospitals and health systems of the Denver Metropolitan area to improve the quality and provide

evidence-based care to the populations their healthcare organizations serve.

Chapter Five presents an interpretation of the findings presented in Chapter Four and the

conclusions, including management and leadership implications, opportunities for future

research. It outlines the final findings related to implementing EBMgt-EBM in healthcare

organizations. It also synthesizes the study’s findings to present contributions concerning the

existing literature on EBMgt and EBMgt-EBM integration.

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 CHAPTER FIVE

The purpose of this exploratory qualitative study was to explore the lived experiences of

senior executive leaders of hospitals who practice EBMgt and its integration with EBM.

Although EBM has been successful as a paradigm shift in the medical field, the use of EBMgt as

a leading paradigm in healthcare management is still not universal as Bosman (2015) indicates.

This study attempted to explore the following overall research question: What can be learned

from senior hospital executives and health systems in the Denver metropolitan area about how to

systematically implement EBM-EBMgt? Chapter Five addresses the interpretation of the study’s

findings and conclusions. It outlines the limitations of this research investigation and its

implications for practice in healthcare management and leadership. It includes recommendations

for future research in EBMgt as well as its integration with EBM in hospital settings.

Despite recent advances in medicine and technology, including the significance of

EBMgt in management decision-making processes (Reay et al. 2009; Rousseau & McCarthy,

2007), still, more than 45 % of the U.S. population does not receive appropriate evidence-based

medical interventions. This observation includes American hospitals in general, even those that

have embraced EBM practices (McGlynn et al., 2003; Shortell, Rundall, & Hsu, 2007). Despite

the expensive and continuous investment that hospitals dedicate to “building information

systems to support operations at various levels of administration,” hospitals have not widely

embraced EBMgt processes (Weiner, Balijepally, & Tanniru, 2014). Therefore, these health

organizations have not widely integrated EBMgt and EBM to leverage the significant amount of

data their systems generate to make evidence-based decisions that ensure effective sustainability

and growth as Weiner et al. suggested (2014). American hospitals might benefit considerably if

senior executives adopt and implement both EBM and EBMgt practices into their organizations

as Shortell et al. (2007) suggested. Chapter Five presents the findings and conclusions of this
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study of EBMgt-EBM integration and its role and impact on strategic hospital management,

including the factors, barriers, and facilitators of its incorporation in healthcare organizations.

Findings and Conclusions

This study addressed EBMgt approaches and explored EBMgt-EBM integration by senior

health executives and healthcare organizations. Hospitals and health systems of the Denver

Metropolitan area constituted the study settings where the research data was collected via

interviews. Due to its exploratory nature, this research study utilized a phenomenological

approach (Creswell, 2014) to derive emerging major themes necessary to understanding

systematic of EBMgt implementation and EBMgt-EBM integration in healthcare practices.

To this end, the researcher conducted nine semi-structured face-to-face and four

telephone interviews to learn about experiences of senior leaders’ and hospitals’ EBMgt

practices. The interview questions also addressed the combination of EBMgt and EBM practices

in health settings, including the impact, contextual factors, and barriers associated with such

integration in hospital evidence-based strategic decision making. The section below outlines the

interpretation of the dissertation findings.

Interpretation of Study Major Themes

Major Theme 1: Conceptualization and understanding of concepts. The findings of

this research demonstrate that hospital executive leaders in the Denver metropolitan area have a

positive view towards EBMgt-EBM integration and believe EBMgt-EBM can enhance the

quality of care and improve hospital performance. All 13 senior hospital executive participants

understood and perceived EBMgt-EBM integration as critical to developing a culture of

evidence-based decision making in healthcare organizations. Therefore, such a positive attitude

towards the linking of EBMgt-EBM may serve as leverage for implementing EBMgt practices

hospitals. However, despite the familiarity of senior executives with EBMgt and their positive
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view of EBMgt-EBM, most health systems have neither implemented EBMgt nor its linking with

EBM. Only 2 participants, in the same hospital, stated that their institution had recently adopted

and initiated a systematic internal EBMgt approach. This hospital used balanced scorecard tools

(i.e., dashboards) to provide the senior leadership team with access and data visualization of the

institution. These scoreboards tools were essential organization capabilities for strategic

decision-making. This result confirmed as Tort-Martorell et al. (2011) concluded, that it was

imperative and logical for organizations to focus their evidence-based leadership efforts on

implementing the internal side of EBMgt first. It is easier for an organization’s executive

management team to establish internal EBMgt processes to help senior executives manage their

institution and make decisions based on internal evidence (Martorell et al., 2011). Rousseau et al.

(2008) maintained that leaders of organizations make good decisions when they base their

decisions on both management research evidence (external EBMgt) and local evidence (internal

EBMgt). Dashboard software, Total quality management (TQM), the Excellence Models or Six

Sigma, all provide a scientific method to learning about the organization’s activities and, thus,

making evidence-based decisions (Martorell et al., 2011).

Overall, participants viewed the integration of EBMgt and EBM as a means for health

institutions to provide an environment where the clinical leaders and the hospital administrators

could work in partnership. Such partnership is paramount to using research evidence

(information) from both EBMgt and EBM principles to provide reliable and high-quality care to

patients and the communities of the Denver metro area.

Major Theme 2: Perceived impact of EBMgt and EBMgt-EBM integration. The

current study also shows that senior hospital executives perceived that EBMgt had a positive

impact on leader’s management practices as well as leadership styles. At the organizational level,

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participants’ responses concerning the extent of EBMgt use by healthcare institutions mirrored

senior executive use as mentioned earlier. Just a few hospitals, one in this study, have systemic

EBMgt practices in place to support evidence-based decision-making outcomes. However, other

hospitals have initiated and implemented dyad leadership teams to include clinical leaders in

hospital strategic decision committees. Dyad leadership, which requires a collaboration from

both the hospital medical leadership and business administrative management (Sanders &

Moore, 2015), is an incremental step toward integration of EBMgt-EBM. Although the pairing of

two leaders from two backgrounds used in dyad management is crucial to accomplishing

organizational goals, it does not guarantee the application of EBMgt principles.

As stated earlier, this study demonstrated that senior health executives and managers,

including their healthcare institutions, have not widely embraced EBMgt leadership practices.

Hence, these organizations may not be able to leverage information (evidence) from EBMgt to

learn about the hospital’s management activities that are essential to accomplishing the health

system’s mission and objectives. According to the study’s conceptual framework, these practices

are vital for healthcare organizations to integrate EBMgt and EBM in support of developing a

culture of evidence-based decision making. Several scholars have indicated that these institutions

lacked organizational structures or processes to facilitate the uptake of approaches such as

EBMgt (Shortell et al., 2007; Denis, Lomas, & Stipich, 2008. Most hospitals also lack EBMgt-

champions, or power-users, with the necessary skills to include EBMgt practices in the

organization’s “ongoing change management activities” (Denis et al., 2008). Thus, there is still a

growing need for further studies, not just on EBMgt utilization within the context of healthcare

organizations as Cummings et al. (2010) indicated but also on the EBMgt and EBM integration

(Shortell et al., 2007).

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 All 13 (100%) participants unanimously agreed that EBMgt-EBM integration would also

positively influence hospital performance by enhancing accountability and transparency of the

senior leaders’ decision-making process. Ten of the 13 participants reported that EBMgt would

yield supportive relationships that were vital to improving hospital performance and fostering a

culture of evidence-based decision-making in healthcare settings. This result corroborates with

the conceptual framework that highlights the need for better understanding the context (EBMgt)

and content (EBM), including processes senior executives us, as Anderson et al. (2011)

suggested, for hospitals to reliably provide evidence-based care to patients. Although 9 senior

hospital decision-makers perceived that EBMgt-EBM integration would yield evidence-based

outcomes, 8 thought it would improve EBMgt competencies and skills of leaders. Also, 6

participants noted EBMgt, including EBMgt-EBM integration, would encourage hospital

executive leadership teams to seek appropriate training for staff empowerment and efficient

organization transformational leadership approaches to ensure hospital sustainability and growth.

The participants’ responses were in alignment with the conceptual framework of this

study. Executive leaders of healthcare organizations need to embrace not only EBMgt but also

integrate EBMgt and EBM practices. HakemZadeh (2016) suggested that an EBMgt

collaboration is necessary to provide organizational leaders with a systematic approach that deals

with and finds solutions to organization issues. Such collaboration is indispensable in promoting

EBMgt principles to instill and increase using management research evidence in health

organizations (HakemZadeh, 2016). By so doing, hospitals would gain a better understanding of

the required context, content, and processes needed to start building a culture and organizational

capacity that promotes using evidence (EBMgt) to deliver quality evidenced-based healthcare

99
(Sullivan, Orchard, Umoquit, 2011). For this reason, hospitals and health systems must have

effective leadership and EBMgt processes in place.

Theme 3: Perceived Factors and barriers of EBMgt, and EBMgt-EBM. The third

major theme discussed 13 healthcare senior leaders’ responses related to the study interview

questions about factors, barriers, and EBMgt-EBM facilitators. Participants perceived that two

significant primary contextual factors were essential to integrating EBMgt and EBMgt-EBM in

healthcare organizations: (1) organization culture and (2) leadership. Eight of the 13 participants

cited healthcare organization culture and 7 identified hospital leadership. These factors were

perceived as necessary for hospitals to be able to implement a systematic use of EBMgt practices

in decisions making. Findings of this major theme were consistent with the results that Rundall et

al. (2009) reported. Equally important concerned barriers and how to adopt and implement

EBMgt (or EBMgt-EBM integration). As such, hospital decision-makers identified leadership

and organizational culture as the fundamental contextual obstacles.

Theme 4: EBMgt Senior leadership team or EBMgt champion. To successfully

incorporate EBMgt, 11 study participants perceived that healthcare organizations have an EBMgt

leadership team responsible for facilitating and coordinating organizational efforts that embrace

EBMgt and EBM systematically integration. Although some participants desired to include

CEOs and CMOs in such a team, others preferred to have the role of EBMgt-facilitator or

champion assumed by outsiders such as consultants. HakemZadeh (2016) indicated that

executive decision-makers need “reliable evidence to make sound and efficient decisions.” For

this reason, he suggested establishing an independent organization team responsible for

reviewing and evaluating management research findings (external evidence), including

100
institution local data (internal evidence), and assessing the strength of evidence that may serve in

strategic decision making.

Theme 5: Systematic integration of EBMgt-EBM in hospitals. The final finding of

this research project was a lack of systematic EBMgt processes and infrastructure necessary to

support the implementation of EBMgt practices and EBMgt-EBM integration. As previously

noted, study participants viewed the existence of an EBMgt senior leadership team as

indispensable in promoting and adopting EBMgt practices. As such, all 13 participants expressed

the significance for healthcare organizations to have defined processes and infrastructures in

place to support EBMgt practices. Participants reported a lack of such structures in their

organizations.

For the senior leadership team to systematically implement EBMgt, hospitals and health

systems of the Denver metropolitan area must have a culture of critical thinking thought-process

in place. As shown earlier in Table 14, all 13 participants shared the thought that the

development of an EBMgt culture requires hospital decision-makers to provide an environment

where critical thought processes and a culture of strategic questioning become the norm.

Consequently, hospitals and health systems have to develop an organization culture that is more

open to change or improvement. Additionally, participants (5 or 38%) also indicated that access

to EBMgt published materials was essential to promote and support such this culture and EBMgt

activities. Participants viewed healthcare organization leadership and culture as necessary to

adopting and implementing EBMgt.

From the above five major study themes, there are some key findings of this exploratory

qualitative study that are worth noting. First, the interviewed healthcare executives were familiar

with the concept of EBMgt and had a positive attitude toward EBMgt-EBM integration. This

101
finding suggests such a positive attitude might serve as leverage to accelerate the uptake of

EBMgt and its systematic implementation in health systems. Senior hospital decision-makers

believe that EBMgt-EBM can have a significant impact on the quality of care that hospitals

deliver to their patients and communities and their organization strategic management decisions

and overall performance. Second, most hospitals and health systems in the Denver Metropolitan

area have still not implemented EBMgt practices systematically. These healthcare organizations

lack EBMgt processes and infrastructures that are necessary to the implementation of EBMgt-

EBM integration. Third, the study findings revealed that hospital executive leadership and

organization culture were the most important factors to implement EBMgt and its integration

with EBM systematically. The results of this study also show that lack of EBMgt-champions

(facilitators) is a significant obstacle to the uptake of EBMgt practices in healthcare

organizations.

Limitations of the Study

In conducting this study, the researcher noted several areas where considerable

improvement could have enhanced the quality of the investigation’s findings. First, due to its

exploratory qualitative nature, the study was limited by researcher and participant biases, which

can result in personal beliefs affecting the study. To overcome his these biases, from prior

experience with data-driven decisions in the pharmaceutical industry, the researcher used

bracketing (Dowling, 2007; Tufford & Newman, 2012) to allow an untainted understanding of

participants’ perspectives and experience about EBMgt and EBMgt-EBM integration. Bracketing

was necessary for this phenomenological study as it assisted the researcher in reducing or

eliminating the influence of bringing in personal opinions and beliefs.

Second, the study involved 13 participants, which was a small sample size and not

sufficient to be representative of the decision-makers in hospitals and health systems within the
102
entire greater Denver Metropolitan area. With such a limited number of participants, a qualitative

study is prone to validity and reliability issues. However, the broad inclusiveness of the

participants’ demographics, educational background, and professional management experience

provided different and deeper insights related to the extent of use, challenges, and implications of

EBMgt-EBM implementation of hospitals in the Denver area.

Third, the research project study was limited to the fellows and members of the American

College of Healthcare Executives. This limitation was significant because not all hospital senior

leaders opt to become affiliated with this entity. Thus, not having included the perspectives of

such decision-makers was another aspect that constituted a major limitation of the study. Also,

the inclusion of more participants, the non-American College of Healthcare Executives, could

also have increased the sample size of this qualitative study to ensure additional significant

perceptions.

Fourth, although the study participants came from four health systems in the Denver area,

not many interviewed senior executives were from the same hospital. Of the 13 decision-makers,

2 worked at one local organization, 3 at another health institution, and the rest of the participants

came different hospitals. Interviewing one informant from a given institution was a significant

limitation to obtain a better understanding of EBMgt practices, including a broad view of its

processes and infrastructures, within a hospital or health system. The participation of 2-3 senior

leaders or a focus group might yield more data. However, having done so would have required

additional scheduling and potential cost implications to obtain the interviews.

Finally, in addition to the small sample size, the research endeavor was geographically

limited to the Denver Metropolitan area. These two aspects of the study constituted significant

limiting factors to the generalizability and transferability of the research findings. Therefore, the

103
findings of this study could not be generalized to all senior leadership teams of hospitals and

health systems in the Denver area because of a limited number of participants. A larger sample

size could have been essential to guarantee a strong representation of the study population;

however, because of the interview scheduling challenges with senior hospital managers, such a

sample size could not be achieved within the time allocated by the researcher’s academic

institution.

Implications for Practice

The overall goal of this study was to learn how senior hospital executives understand and

perceive the phenomenon of linking EBMgt (i.e. the context of providing care) and EBM (i.e. the

content of providing care) in hospitals in the Denver Metropolitan area. The findings of this

qualitative exploratory study provided substantial information that can have several practical

implications for the implementation of EBMgt and EBMgt-EBM integration in hospitals and

health systems. First, it is essential for health executives to assess the current extent of EBMgt

practices at all leadership levels and the hospital level as a whole system in their institutions to

establish a baseline for evidenced-based leadership practices. Health systems seeking to integrate

EBMgt-EBM should not only understand the challenges and barriers associated with

implementing EBMgt (Kovnor et al., 2014), but also the required transformational leadership

and organization culture shift needed to achieve such an endeavor.

With the current ever-changing American healthcare business environment, all hospital

decisions, highly visible hospital decisions such as mergers, acquisitions, and less visible ones

such as recruiting and retaining personnel, can have a significant impact on the hospital

management’s strategic mission and vision (Rundall et al., 2007). Hence, it is the responsibility

of senior health administrators to ensure all executives use the best available research evidence in

strategic decision-making to demonstrate good stewardship of organizational resources and

104
performance. At the leadership level, study participants underscored the need for senior hospital

leaders to first incorporate EBMgt in their daily management and leadership activities and to

model its practices and, thus, showing its importance in organizational decision-making. The

study’s findings highlighted, based on participants' perception, that practicing EBMgt and

EBMgt-EBM is necessary for healthcare organizations to be able to provide reliable and high-

quality evidence-based care.

The second implication was that health executives have the responsibility to transform

their institutions’ structures and culture and to create a supportive environment that fosters an

evidence-based decision making culture. It is evident from this research that healthcare

organizations lacked systemic infrastructure and processes that promote and support using

EBMgt. Hence, for hospitals desiring to achieve EBMgt-EBM integration, a hospital leadership

team should consider creating an EBMgt committee responsible for establishing EBMgt

guidelines and, thus stating the due diligence requirements for strategic and management

operating decisions.

Third, healthcare organization executives can use this exploratory qualitative study’s

findings as they reflect upon the development of an EBMgt collaboration that can enhance

supportive relationships between hospital administrators and the clinical medical leadership. This

collaboration may benefit health institutions by compelling the decision-makers to work together

and put in place hospital structures and processes that promote EBMgt use. Hence, this

investigation may help executive leaders of hospitals and health systems to learn from the values

of EBM (i.e., making medical decisions based on best available research evidence) to create and

sustain a questioning culture in management decision-making. To that end, Rundall et al. (2007)

proposed three strategies to help healthcare organizations build such a culture. Hospital

105
executives need to (1) request for evidence supporting important decisions, (2) participate in

EBMgt educational training, and (3) explore recently published EBMgt research publications to

assess the suitability to their organization contexts.

Based on this study, participants perceived the role of a hospital EBMgt- champion as

significant to help implement EBMgt and EBMgt-EBM integration in hospitals. This finding

implies that health systems may consider having a small organization team of EBMgt committed

executives as a precondition to implementing EBMgt practices and integrating with EBM. Denis

et al. (2008) note that most hospitals not only lack EBMgt-champions, or power-users, with the

necessary skills to include EBMgt practices in the organization, but they also lack organizational

capabilities to promote using research evidence (EBMgt) in decision making. Thus, each hospital

or health system should first assess its needs concerning capability for facilitating and

coordinating organizational efforts to embrace EBMgt and integrate it with EBM systematically.

HakemZadeh (2016) suggested establishing an independent organizational team who is

responsible for reviewing and evaluating management research findings, including internal

institution evidence, and assessing the strength of such evidence for strategic decision making.

An EBMgt leadership team or committee might be helpful in building an organization’s

evidence-based research capabilities needed to address management decision issues (Rundall et

al., 2007). To improve their organization’ performance, senior hospital leaders should consider

attending programs such as the Executive Training in Research Application to solidify and

further their understanding of EBMgt as it pertains to decision-making (Adams & Rochon,

(2011).

Finally, the study’s findings suggested that for systemic EBMgt- EBM implementation

integration to occur in Denver hospitals and health systems, senior leaders of these health

106
institutions should create EBMgt organizational structures, processes, and cultures that promote

and support EBMgt use. The following actions, as Kovner et al. (2009) pointed out, may serve as

recommendations for health systems to develop a culture of evidence-based decision making.

First, hospitals need to implement systematic processes to make evidence-based decisions to

demonstrate their leadership commitment to both EBMgt and EBM. Second, healthcare

organizations should provide managers, at all leadership levels, with a periodic briefing on recent

management research findings that might impact the hospital’s management operational and

strategic concerns in three areas of EBMgt as previously discussed in this study. That is (a)

operational management, (b) strategic management, and (c) core business transactions. Third, an

organization EBMgt leadership team should assist in incorporating its management research

assessments into a hospital’s due diligence findings. With defined EBMgt processes, executives

at all leadership levels are to demonstrate their commitment to both EBMgt and EBM practices

to ensure accountability and transparency in organization strategic decision-making. Another

action is that EBMgt champions or facilitators should initiate an organization-wide leadership

training about EBMgt practices and processes. Last, but not least, hospitals should also maintain

supportive relationships with academic and research institutions. Such partnership will be

indispensable not only in helping to encourage hospital managers and practitioners to stay

abreast of recent publications of evidence-based management and leadership but also to have

opportunities to participate in EBMgt and practice new management research approaches.

Klopper-Kess et al. (2010) maintained that cooperative and supportive relationships between

hospital management and clinical leadership are valuable to enhance hospital performance. Thus,

integrating EBMgt-EBM is essential not only to developing such cooperation but also to helping

107
administrative and medical executives work together to establish hospital operational metrics

(Pine et al., 2012) that tie to their organization performance.

Recommendations for Future Research

Since the publication of the work “Improving Patient Care by Linking Evidence-Based

Medicine and Evidence-Based Management” (Shortell et al., 2007), there has been no further

research study on the integration of EBMgt and EBM. This exploratory qualitative study is the

first study that seeks to extend the initial effort of Shortell et al. (2007) to open doors to new

research opportunities in the area of EBMgt-EBM integration. This study is the first to explore

the understanding and perceptions of senior hospital executives regarding linking EBMgt and

EBM since Shortell et al.’s work. This small study identified the extent of EBMgt use in

healthcare organizations, its impact on senior leaders’ and hospital’ management practices and

performance. It also explored the benefits, contextual factors, and barriers, including the role of

EBMgt facilitators (or champions) to systematically implement EBMgt-EBM. Although this

study constituted a small contribution to the body of knowledge on this issue, it opens doors to

potential research that explores management and leadership issues related to EBMgt and EBM

integration in hospitals and health systems.

Based on this study’s findings, several recommendations may be warranted. First, a

future research study is recommended to include a larger participant sample size to also account

for non-ACHE executives as well. The participants should include executives from hospitals and

health systems other than those working in the Denver area. Furthermore, extending this research

endeavor to a statewide and nationwide study would enhance understanding the phenomenon of

integrating EBM and EBM in American healthcare organizations.

A second recommendation is that future research should be conducted as a comparative

study to examine differences between hospitals that have implemented EBMgt-EBM and those
108
that have not. Another study could be to expand this research effort to compare rural and

metropolitan healthcare facilities and the differences regarding the adoption of EBMgt and

EBMgt-EBM integration. Also, health scholars and practitioners may undertake actions research

projects to help health systems implement both EBMgt practices and EBMgt-EBM integration.

Hence, some of the future research efforts may involve conducting cross-sectional and

longitudinal studies within healthcare organizations. Additionally, other research endeavors may

include doing similar studies in other regions (areas) as well as in other countries.

Reflections

As a research and development pharmaceutical professional, undertaking this exploratory

qualitative research project has allowed the researcher to appreciate qualitative research design

better. Using semi-structured interview questions provided this researcher the opportunity to

understand that participants’ in-depth responses generated new ideas and insights on the topic of

EBMgt and its integration with EBM that had not been considered based on his quantitative

scientific experience. As a researcher, understanding qualitative research grew throughout the

doctoral journey. Additionally, a significant amount of the data generated by interviews was

overwhelming and required professional data coding and data analysis software. Despite these

challenges, the researcher was moved by the excitement and willingness some healthcare

executives showed to participate in this research study. Most of these hospital decision-makers

communicated their desire to have access to this investigation’s findings to learn more about

EBMgt and EBMgt-EBM integration. Participants, senior hospital executives, viewed this study

as worthwhile and thought it would be useful to healthcare organizations and add value to the

existing body of literature.

109
 Conclusion

Based on the findings and conclusions of this study senior hospital leaders and their

healthcare organizations may benefit from embracing and adopting both EBM and EBMgt as

these two constructs may foster a culture of evidence-based decision making. A great need exists

for understanding how the two principles, EBMgt (context for providing care) and EBM (content

for providing care), interact to provide high-quality care and effective leadership that is essential

to improving hospital and health systems performance. Decision-makers, senior administrators,

and medical staff leaders are necessary components of healthcare organizations to developing a

culture of accountability and transparency in making strategic decisions. To cope with the ever-

increasing pace of business change in the 21st-century, hospital leaders should consider the

implications of EBMgt practices and EBMgt-EBM might have on evidence-based strategic

management and performance of their institutions. Hence, hospital organization training on

EBMgt practices would be prudent to help administrators understand the EBMgt-EBM concept.

For the senior leadership team to systematically implement EBMgt, Denver metropolitan area

hospitals and health systems must have a critical thinking thought-process culture in place that

supports both EBMgt and EBM.

110
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 Appendices

Appendix A: Invitation to Participate in a Dissertation Research Study

Charment Moussata
Healthcare Management & Leadership
Colorado Technical University
E-mail: Charment.moussata1@student.ctuonline.edu
Phone: (xxx) xxx-xxxx

October 23, 2016

Participant address block

RE: Invitation to Participate in a Dissertation Research Study

Dear,
My name is Charment Moussata, and I am a graduate student in the "Healthcare
Management and Leadership" program at Colorado Technical University (CTU). I am currently
an associate student member of the American College of Healthcare Executives (ACHE), and I
am working on a research project for my dissertation.

The purpose of this study is to learn about Evidence-Based Management (EBMgt), its
impact on practices of senior executive leaders and managers, including organizational strategic
decision-making and performance, of hospitals and health systems operating in the Denver
Metropolitan area. It also aims to help understand the perceived influence of EBMgt integration
with Evidence-Based Medicine (EBM) and other healthcare organization strategic management
areas.

You are being asked to participate in this study because of your experience in leadership
and management of hospitals and health care systems. With your expertise as the executive
administrator, including your knowledge as a Fellow of the ACHE, I believe you will provide
new and deeper insights to my dissertation research project. Therefore, your perceptions and
perspectives on the overall research question of this study are critical to understanding
organizational issues associated with EBMgt and its impact on strategic decision-making and
performance of hospitals and health systems. For more information about the participants,
procedure, and the benefits of this study, please see the attached Informed Consent Form.

I would like to interview you and other members of your organization executive
leadership team to gain an understanding of the senior leaders’ perspectives and perceptions
regarding the integration of EBMgt and EBM practices in hospitals and health systems in the
Denver area. The interview process will take 30 to 60 minutes to complete.
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 I will greatly appreciate your participation in this academic research endeavor. If I do not
hear from you, I will contact you with a telephone call or email for a follow-up by Wednesday,
November 9, 2016. I look forward to addressing some questions or concerns that you may have
at that time. You may contact me at Charment.moussata1@student.ctuonline.com or (xxx) xxx-
xxxx). You may also contact my dissertation advisor, Dr. Daphne DePorres at
DDePorres@coloradotech.edu.

Should you agree to participate voluntarily in this study, please sign and return the
attached Interview Consent Form so that I can arrange a one-on-one meeting (or telephone
interview) with you.

I look forward to talking with you soon.

Sincerely,

Charment Moussata
Doctoral Candidate, Healthcare Management & Leadership, Colorado Technical University

Enclosure
cc: Dr. Daphne DePorres, Dissertation Mentor, Business & Management, Colorado Technical

University

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 Appendix B: Study Informed Consent

Title of Study: The implementation of evidence-based management and its influence on the practices
of senior leaders of hospitals in the Denver metropolitan area that practice evidence-based medicine

Investigator: Charment Moussata

Contact Number: (xxx) xxx-xxxx

Purpose of the Study

You are invited to participate in a research study. The purpose of this study is to learn about
evidence-based management (EBMgt) and its influence on practices of senior executive leaders, including
strategic healthcare decisions and performance, of hospitals and health systems in the Denver
Metropolitan. It also aims to help understand the perceived influence of the integration of EBMgt on
hospital performance.

Participants

You are being asked to participate in the study because you are in a leadership position that makes you
one of the most likely hospital executive team members to be familiar with the various management
practices and organization performance of hospitals. Therefore, your opinions and perspectives on the
overall research question of this study are critical to providing deeper insights and understanding
organizational issues associated with the integration of EBMgt and EBM.

Procedures

If you volunteer to participate in this study, you will be asked to do the following: Sign a consent form to
express your willingness to take part in this study and answer questions in a 45-60 minute audio-recorded
interview. Since your participation in this research study is voluntary, you may choose to withdraw from
the study at any time before or during the interview process, up until the interview is completed.

Benefits of Participation

There may/may not be direct benefits to you as a participant in this study. However, we hope to learn how
EBMgt influence practices of hospital management practitioners and leaders in a sampling of healthcare
institutions that practice EBM. Thus, the benefits of this study will include (1) informing the current
management and leadership literature about the significance of the integration of EBMgt and EBM in the
healthcare field and (2) guiding future research on the use of management research evidence in strategic
decision making.

Risks of Participation

There are risks involved in all research studies. This study is estimated to involve minimal risk. An
example of this risk is taking the time out of your busy schedule and possibly feeling uncomfortable
answering question about your organization.

Cost/Compensation

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This will be no financial cost to you to participate in this study. The study will take 45 to 60 minutes to
complete an interview to gather your perspective. You will not be compensated for your time. Colorado
Technical University will not provide compensation or free medical care for an unanticipated injury
sustained as a result of participating in this research study.

Contact Information

If you have any questions or concerns about the study, you may contact the (1) the research investigator,
Mr. Charment Moussata (at charment.moussata@student.ctuonline or 303-578-8260) and (2) the
dissertation mentor/faculty member, Dr. Daphne DePorres (at ddeporres@ctuonline.edu or xxx-xxx-
xxxx). For questions about the rights of research subjects, any complaints or comments regarding the
manner in which the study is being conducted, you may contact Colorado Technical University –
Doctoral Programs at 719-598-0200.

Voluntary Participation

Your participation in this study is voluntary. You may refuse to participate in this study (or in any part of
the study). You may withdraw at any time without prejudice. You are encouraged to ask questions about
this study at the beginning or at any time during the research study.

Confidentiality

The investigator will securely store responses to the interviews to maintain the confidentiality of the data
collected from participants by using a 256-bit encryption FIPS 140-2 level 3 compliant USB drive. The
researcher will ensure that all information (from written notes and audio recorded interviews) is digitized
and stored on this encrypted device immediately upon completing interviews. The researcher will destroy
the original raw data (i.e. tapes of interview recordings and field notes) to protect the privacy of the study
participants. Upon the publication of the findings of this dissertation, this health management researcher
will destroy copies of the data contained in the FIPS 140-2 USB drive.

Participant Consent

I have read the above information and agree to participate in this study. I am at least 18 years of age. A
copy of this form has been given to me.

___________________________________________________________

Signature of Participant Date

______________________________________

Participant Name (Please Print)

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Appendix C: Interview Protocol Guide

Charment Moussata
Healthcare Management & Leadership
Colorado Technical University
E-mail: Charment.moussata1@student.ctuonline.edu
Phone: (xxx) xxx-xxxx

Interview Protocol Guide

Date of Interview: _____________________________________________________

Location of Interview: _____________________________________________________
Investigator (Interviewer): _____________________________________________________
Name if Informant (Interviewee): ______________________________________
Title of Informant: ______________________________________
Years in current position: ______________________________________
Informant contacts (email, phone): _________________________________________

To facilitate note-taking, I would like to audio record our conversation today. This was
outlined in the Informed Consent Form I provided in my email. Fundamentally, this document
states that: (a) all information shared through this interview is confidential, (b) your
participation is voluntary, and you may halt the interview at any time, and (c) I do not intend to
inflict any harm on you or your organization. The recording will ensure I represent and interpret
your ideas and perceptions accurately. For your information, only I will be privy to the
recordings which will be eventually destroyed after they are transcribed. Thank you for agreeing
to participate. I have planned this interview to last no longer than 60 minutes. During this time, I
have a few questions that I would like to cover. You will have ample time to answer all questions
in as much detail as you wish.

10. In your position as an executive leader, what is your understanding of the following
concept concepts?
(a) Evidence-based Medicine (EBM)?
(b) Evidence-based Management (EBMgt)?
(c) Integration of EBMgt and EBM?

11. What roles would you say these two concepts play in making hospital strategic
decisions and why?
a. EBM?
b. EBMgt?
c. What are your beliefs and perceptions about EBMgt?

12. Please describe a typical way in which your institution uses (or could use) evidence
from both EBMgt and EBM to make strategic decisions in each of these three areas:
a) Core business transactions,
b) Operational management,
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 c) Strategic management

13. To what extent are you using EBMgt in your current leadership decision-making
position?
a. Can you provide examples of how EBMgt is benefiting your organization
management practices?
b. How does EBMgt affect your personal managerial practices?
c. How do you perceive the affects EBMgt has on your management style?
Negative/positive and Why?
d. How about EBMgt impact on other senior executives’ management
practices and styles
e. If not, how do you think EBMgt can affect senior leaders’ managerial
practices?

14. What is your perception of your organization in linking (combining) EBMgt and
EBM practices to provide better care? What role do you think the combination of
EBMgt and EBM plays in the development of an evidence-based decision-making
culture in this organization?

15. How do you feel about the influence the EBMgt-EBM integration has on the
accountability and transparency of the senior leaders’ decision-making process in
your hospital’s (or health system) strategic decisions?

16. How do you think the integration of EBM and EBMgt practices will change the
beliefs and attitudes of healthcare CEOs and other senior leaders towards embracing
EBMgt? What role do you think that this combination could (might) play to help
hospitals and health systems embrace EBMgt practices to develop a culture of
evidence-based decision making?

17. How and when do you think senior executives in your organization should make use
(or could) of evidence from EBM and EBMgt when making strategic decisions? What
is the process you currently use in your organization when making strategic decision?
Has the process proven beneficial?

18. What do you perceive to be the most important contextual factors for a systematic
integration of EBMgt and EBM to occur in a health care practice?
a. What are the barriers?
b. Who in your organization are (could be) the facilitators who can ensure
this integration happens and why?

133
19. Is there any additional information you like to share? Do you have any contacts in
the healthcare management and leadership field you feel would be an asset to my
research?

134
 Appendix D: Denver Metropolitan Area Map

Figure 2.1. Denver Metropolitan Area Counties

135
 Appendix E: Demographic Characteristics of Participants

Table 4.15 Demographic Characteristics of Participants

Participant #ID Titles or Positions Gender Managerial Experience Education

RP1_161004 VP Female 10 years DBA

RP2-161005 SED Female 9 years DHSc.

RP3-161007 VP Female 5 years MBA

RP4-161019 SED Male 6 years Master’s

RP5-161024 VP Female 3 ½ years Master’s

RP6-I61024 VP Male 4 years MBA

RP7-161025 SED Female 2 years PhD

RP8-161109 CFO Male 2 years MHA

RP9-161110 CEO Male 8 years MHA

RP10-161114 COO Male 5 years Master’s

RP11-161115 CEO Male 12 years MBA

RP12-161116 CEO Male 4 years MBA

RP13-161118 CEO Male 4 years MBA

To protect the anonymity of participants and their institutions, the researcher assigned

participants identification numbers (#IDs) as shown in Table 4.15. For example, RP1-161004,

RP9-161110, and RP13-161118, with RP1, RP9, and RP13 corresponding the order of interviews

that research participant 1, 9, and 13 completed, respectively. The numbers 161004, 161110, and

161118 were automatically generated by the recording device, Sony ICD-UX533, and

represented the interview schedule date in the format YYMMDD. Note: The anonymized source

136
for qualitative data is included at the end of each quote using alphanumeric coding. The

investigator used this participant anonymization scheme (i.e. RP, RP2, RP3, etc.) throughout the

remaining sections of the dissertation to attribute quotes to appropriate study respondents

accordingly.

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 Appendix F: Listing of Coding Reports

Total: 12 coding reports with 103 subcategories. Titles sorted alphabetically

1. Q00. Position-Responsibilities
2. Q01. Concepts EBM EBMgt (3 subcategories)
 EBM
 EBMgt
 Integration
3. Q02. Strategic Roles EBM EBMgt (3 subcategories)
 EBM
 EBMgt
 Your beliefs perceptions EBMgt
4. Q03. Typical Use EBM EBMgt (4 subcategories)
 Core business transactions
 Operational management
 Strategic management
 Construction
5. Q04. Extent Current Use EBMgt (5 subcategories)
 a-Organization management practices (5 subcategories)
 50-60%
 85-90%
 Mixed results
 Most or all the time
 Not very well
 b-Personal managerial practices (5 subcategories)
 50%
 70%
 85-90%
 Situational
 Tremendous impact
 c-Affects your management style (4 subcategories)
 No effect
 Personalize style
 Positive impact
 Situational
 d-Impact other Senior executive practices styles (3 subcategories)
 80%
 Most or all of them
 Situational
 e-If not, how could it affect their practices
6. Q05. Provide Better Care (8 subcategories)
 Competencies and skills
 Competing benchmarks
 EB outcomes

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  Financial
 Lead by example
 Patient satisfaction
 Staff empowerment
 Training
7. Q06. Influences- Senior Leaders (6 subcategories)
 Accountability
 Lead by example
 Organizational performance
 Supportive relationships
 Training & education
 Transparency
8. Q07. Embrace Change CEOs Senior Leaders (7 subcategories)
 Awareness - Buy-in
 CEO influence
 Holistic view and authority
 Infrastructure
 Physician incentives
 Scientific rigor
 Systemic control
9. Q08. Current Strategic Processes (3 subcategories)
 Current & is it beneficial
 How & when should or could use
 Q08 Not asked - interview cut short
10. Q09. Contextual Factors (4 subcategories)
 Barriers (10 subcategories)
 Competition
 Data issues
 Hierarchy issues
 Lack of commitment
 Lack of trust
 Policies & structure not in place
 Priorities
 Resistance to authority
 Resistance to change
 Senior leadership issues
 Facilitators (8 subcategories)
 Board level third party
 CEO
 CFO COO HRO CNO
 CMO
 Documentation (guide)

 Non-traditional leaders
 Senior leadership

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 Most important (10 subcategories)
 Awareness
 Compliance controls
 Culture
 Data evaluation
 Infrastructure
 Intangible factors
 Leadership buy-in
 Needs analysis
 Resources
 Training and education
11. Q10. Anything Else (4 subcategories)
 Contact recommendations
 General comments
 Infrastructure advantage in Colorado
 Published materials EBMgt
12. Systematically implement EBMgt (1 coding report with 11 subcategories)
 Accountability
 Competent qualified people
 Culture - Ingrained thought-process
 Defined process and infrastructure
 Open to improvement
 Partnering
 Play to people's strengths & weaknesses
 Published materials
 Relationships - trust
 Strategic questioning
 Transparency

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