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Evidence-Based Practice: Advantages, Disadvantages, Models
Healthcare Organization and Management · Chapter 18: Evidence-Based Practice in HealthcareSection 18.3 · lesson 104 of 1059 min · free with a free account
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In this lesson
Choosing implementation models and weighing honest criticisms of evidence-based practice.
- Classify implementation models as process models, determinant frameworks, or evaluation frameworks
- Compare the Iowa, Johns Hopkins, Stetler, and ACE Star process models
- Evaluate the main advantages and criticisms of evidence-based practice
- Describe how to decide responsibly when evidence is absent
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Transcript
Everything said in the video, section by section (1,113 words). Read along, or search it.
Opening Case
Three Teams, Three Different Models
Larkfield's evidence-based practice council has a new problem. Three teams have started practice changes, and each picked a different model, because that's what its leader learned. One team has a beautiful flowchart, and no change on the unit. Another can't tell whether its project worked. The five steps say what has to happen. They don't say who does it, in what order, what helps or hinders, or how to judge success. So which model should a team use? And what are the honest arguments against this whole approach?
Why Models
Structure That Can Replace the Work
Models fill those gaps. They give a team a shared vocabulary and a checklist, so nobody has to invent the structure, or discover halfway through that a step was skipped. Their risk is just as practical. Adopting a model can replace doing the work, leaving a well-documented process and no change in practice.
Model Families
Process, Determinant, and Evaluation Frameworks
Implementation researcher Per Nilsen sorted the many published models into families, by the question each one answers. Three matter here. Process models sequence the work, from problem to evaluation. Use one when the difficulty is: what do we do next? Determinant frameworks list what makes implementation succeed or fail. The well-known Consolidated Framework for Implementation Research, CFIR, groups them into the intervention, the inner and outer settings, the individuals, and the process. Evaluation frameworks say how to judge the effort. RE-AIM, for example, asks about reach, effectiveness, adoption, implementation, and maintenance. They aren't rivals. A team can use a process model for the work, a determinant framework to diagnose, and an evaluation framework at the end.
Process Models
Iowa, Johns Hopkins, Stetler, and ACE Star
Four process models are widely taught. The Iowa Model began at the University of Iowa Hospitals and Clinics, published by Marita Titler and colleagues in nineteen ninety-four, and revised in twenty seventeen. It starts from a trigger, a problem or new knowledge, asks whether the topic is a priority, gathers and appraises evidence, pilots the change, and decides whether to adopt it. The Johns Hopkins model, developed by Hopkins nurses, runs a three-phase process called PET: practice question, evidence, and translation. The Stetler model, from Cheryl Stetler, has five phases built for the individual practitioner: preparation, validation, comparative evaluation and decision, translation, and evaluation. And the ACE Star model, from Kathleen Stevens in San Antonio, follows knowledge through five forms: discovery, evidence summary, translation, integration into practice, and evaluation. All four sequence the work. None of them, on its own, tells a team why a change is stalling.
Advantages
Three Reasons the Approach Is Worth Its Cost
Why bother at all? Three advantages justify the cost. First, it reduces unwarranted variation, which is a question of equity as much as effectiveness. Second, it makes reasoning transparent. A decision that names its evidence, its expertise and the values it weighed can be examined, argued with, and revisited. Third, it gives a defensible basis. When a decision is challenged later, in a review or in court, reasoning recorded at the time beats reasoning rebuilt afterward.
Quick Check
Judging a Finished Falls Pilot
Quick check. Larkfield's falls team has finished a pilot. Before spreading it, the board asks how many eligible patients it reached, and whether units adopted it. It also asks whether it was delivered as designed, and whether it lasted. Which kind of framework fits those questions? Pause, and decide. An evaluation framework. Reach, adoption, delivery as designed and maintenance are exactly the kind of questions RE-AIM asks: did it work, and did it last? A process model is tempting, because the team has just finished a process. But the question now isn't what to do next. It's how to judge what happened.
Criticisms
Five Objections at Full Strength
Evidence-based practice has serious critics, and a manager should be able to state their objections at full strength. Five come up most. One: the evidence base is skewed. What gets studied is what's easy and fundable, so complex conditions and marginalized groups are underrepresented. That's largely true, and a reason to read critically. Two: it undervalues professional judgment. That attacks the misreading. Expertise is one of the three components, though unexamined judgment is often wrong too. Three: guidelines get applied to unlike patients. A real risk. Fit is a formal appraisal question, and departing from a guideline isn't automatically an error. Four: evidence gets cited selectively, to justify decisions made for other reasons. That's misuse, not method. The defense: state the question first, record what didn't fit, and get an independent review. Five: absent evidence gets read as negative evidence. As Altman and Bland put it in nineteen ninety-five, absence of evidence is not evidence of absence. So two criticisms are largely right, two attack misuse, and one attacks a misreading.
Poor Fits
Where Evidence-Based Approaches Struggle
Management questions face all of this with extra force. Controlled comparisons between organizations are rare, context is part of the cause, and published accounts are mostly success stories. So treat outside management evidence as hypotheses, weight your own local data more, and test before committing. That isn't a lower standard. It's the right one for the field. Three situations fit the approach poorly. Novel situations have nothing to appraise, so reason from principles, get fast feedback, and admit the uncertainty. Value-dominated choices can't be settled by evidence at all. And time-critical decisions come faster than evidence can be gathered, so the appraisal has to happen beforehand, in standing protocols.
Quick Check
An Unstudied Handoff Proposal
Quick check. A manager proposes a new handoff between radiology and the emergency department. The board turns it down: there's no evidence for it. She checks, and finds nobody has ever studied it. What's the best next step? Pause, and decide. Pilot it, with a measure. Nobody has studied it, so the missing evidence says nothing about whether it works. It only shows what nobody knows yet. Dropping it is tempting, because no evidence sounds final. But that treats an unstudied practice as if it had been studied and failed.
When Evidence Is Absent
Five Moves Without Evidence
That's the common case, not the exception, so a manager needs a position for it. Five things remain available. Say plainly that the evidence is absent or weak. Reason from mechanism and similar situations, and label that reasoning for what it is. Consult expertise systematically, rather than accepting the most confident voice. Proceed at small scale, with measurement, to build local evidence. And make the decision reversible where you can. Reversibility is worth more the less certain you are. The honest position is to claim no more certainty than exists, and not to be paralyzed by its absence.
Key Takeaways
Models, Critiques, and Missing Evidence
To recap. Models give structure, but can replace the work if you let them. Pick the family by the question: what next, what helps, or did it work. Iowa, Johns Hopkins, Stetler and ACE Star all sequence the work. Two criticisms are largely right. Concede them, and read evidence critically. And when evidence is absent, say so, test small, and stay reversible.
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About Evidence-Based Practice: Advantages, Disadvantages, Models
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