What more evidence do you need?

Should Sally slowly build her case for evidence-based management or does she need to take a more aggressive approach?

This is a cross post from an earlier contribution to the Harvard Business Review blog in March 2010, in anticipation of a fictional case study on evidence-based management in health care, with expert commentaries.

Sally Randolph rose from her swivel chair and walked over to the Norman Rockwell print hanging on her wall. A remnant from the days when she and Mark Wiley worked together as resident physicians, it showed a concerned young girl holding up her doll to a white-haired doctor, who was kindly “listening” to its heart. She loved this image and what it stood for: medicine focused on people. Mark had caught a glimpse of the print in her locker, and back then he had liked it. She wondered what he’d think of it now. They both still worked at American Medical Center, a $2 billion institution with one thousand beds and a $2 billion budget, but Mark was now CEO and Sally chief medical officer. The image of the e-mail he’d just sent— marked urgent with a red exclamation point and the subject line “Evidence-Based-Management Seminar Canceled” — blurred her vision. Apparently the focus for Mark had shifted to profits.

Middle Managers Versus Chiefs
“Hi, Dr. Randolph. Are you interruptible?”

Richard Lee stood with his fist against the door frame, as if he’d been knocking. She wondered how long he’d been there but had a good idea what he wanted.

“Oh, sorry, Richard! Yes, of course. Come in.”

She walked back behind her desk and motioned for Richard to take the seat across from her.

“What’s on your mind?”

Richard was one of the 36 participants in the Evidence-Based-Management (EBMgmt) seminar Sally had run for the past year with Harry Bradshaw, a professor of management at Lucas Business School. Every other month, clinicians and managers had met in teams of six and tackled the management challenges facing AMC. Richard’s team had focused on how to better coordinate patient care.

“I just read the memo from Mark, and, frankly, I’m really frustrated,” Richard said. “I appreciate that he values the skills we acquired in the seminar and says he wants to use them somehow, but making us middle managers on some new task forces won’t change how anyone works. The medical chiefs weren’t receptive to the seminar’s recommendations. What makes him think they’ll be receptive to the practices behind those recommendations? I feel like creating these task forces may just be Mark’s way of softening the blow.”

Sally couldn’t argue with him. His team had tirelessly followed the seminar’s evidence-based approach: translating management challenges into a set of research questions, answering those questions with the best literature out there, and conducting pilot research studies to support the alternative interventions they eventually proposed to senior management.

But despite all the proof of fragmented patient care and the need to improve AMC’s delivery system, the medical chiefs didn’t think the team’s recommended process improvements were more important than their research and teaching. Without support from senior management, the recommendations never made it off the ground.

“I know, Richard,” Sally sighed. “It’s hard to imagine decisions ever getting made differently around here, especially now. You make a very good point, though. If the chiefs weren’t wowed by evidence-based management when Harry and I were the ones selling it, all of you middle managers on the new task forces will have an even harder time getting them on board. I’ll mention this to Mark, but I’m afraid I can’t make any promises.”

She thought of the part in Mark’s e-mail where he talked about Centers of Excellence as a new top priority. These would be run by the chiefs, and with this new responsibility — and power — she worried they’d have even less tolerance for change.

“Thanks, Sally. I appreciate it,” Richard said as he pushed back his chair and stood to leave.

“Well, we’ll see how it goes,” Sally said. But she thought to herself, “Don’t thank me yet.”

Running Out of Options
Deciding to make her morning run six miles instead of three, Sally turned the corner to begin a second loop around the lake. She always entered a sort of Zen state after 30 minutes of pounding the pavement, and today she needed all the clarity she could get.

She knew AMC historically broke even financially, and chatter among senior management hinted that Mark had received clear direction from the board to focus on “not losing money.” One way to boost the center’s financial results was to increase volume, which surely was behind Mark’s new strategic plan.

Centers of Excellence attracted more patients, and more patients equaled bigger profits — in most circumstances. Sally couldn’t help but think that Mark had missed one crucial fact: 90% of AMC’s current patients were low income, and their health care was paid for by Medicare or Medicaid. The chances of the new centers attracting enough higher-income patients to make up for the no-pay patients were slim, especially considering the nicer facilities that already existed in wealthier neighborhoods.

Shaking out her arms on a downhill stretch, she wondered if it was possible to turn the situation from a lose-lose into at least a lose-win. Perhaps if evidence-based management were part of the larger strategic plan, the data would eventually tell the story the EBMgmt team had been trying to tell for some time now.

Before she approached Mark, though, she knew she should probably check in with Harry. He had corun the seminar, after all, and might have some ideas of his own.

A Patient Approach
“Have you tried the stir fry?” Sally asked.

Sally and Harry maneuvered their way around the Lucas Business students bustling through the dining hall between classes. It was a beautiful day — April like it is only in Virginia — and many students were taking their lunches out to the quad. One of them recognized Harry as her professor, giving him a polite smile as she passed with her cell pressed against her ear.

“The stir fry is good, but beware the hot sauce. It’s more garlic than spice,” Harry responded.

“Sally,” he went on, “you know I’ve worked with Mark for 16 years. I know him, and I know AMC. My advice is to start small. There’s just no proof out there that evidence-based management has a high ROI. Limit your efforts to your jurisdiction, to regulating quality and safety, and prove its effectiveness there before trying to convince Mark of broader structural change. We’re lucky that he wants to promote the process at all, considering the seminar didn’t produce any tangible results.”

“But, Harry, Mark’s focus on Centers of Excellence is a definite step in the wrong direction,” Sally said.

“Believe me, I wish the seminar hadn’t been cancelled. I completely agree it’s a bad idea to leave it to the middle managers to enlighten the chiefs. At this point, though, there’s not enough financial or political support for restructuring.”

Back in her office, Sally pondered Harry’s advice. Following his recommendations would take endless months to produce modest results, and for that entire time the center would be pouring resources into a misguided plan to increase profits while moving further away from better patient care.

True, the consequences of not having a seamless delivery system weren’t always dire — one patient receiving a cold meal wasn’t the end of the world. But it really wasn’t acceptable when a high-risk patient had trouble scheduling a crucial follow-up visit or when a patient missed several doses of medication because of miscommunication.

Doing what was right to improve the patient experience was increasingly complex, but every indicator suggested a seamless delivery system was the solution. If the organization seriously committed to using evidence for making better managements decisions, maybe everything else would fall into place. Fostering that sort of commitment would require leadership from the top. And what better way to begin that process than as part of a new strategic plan?

Proof of Evidence
Back at home, Sally plopped down on the couch, mentally exhausted. Her husband, Joe, walked in minutes later with their small dog, Penny, who was excited and straining to be let off her leash.

“How’s it going?” he asked.

She let out a big sigh and recapped her conversation with Harry.

“I can accept not being able to restructure the organization wholesale, but creating these Centers of Excellence shows a complete lack of interest in using evidence to make smart decisions. Mark needs to do more than pay lip service to promoting the ‘great skills’ learned in the seminar. ”

“Well, maybe Harry has a point,” Joe said, unlacing his shoes. “We have all the evidence we need that the U.S. health care system is not sustainable. Our costs are too high, quality is too uneven, and millions of people can’t even get care. Still, all that evidence hasn’t resulted in the right changes. Proving the value of evidence-based management is going to be tough.”

Sally’s look told him that wasn’t the reaction she wanted.

“But why do I need to prove its value first?” she asked. “Is there a known positive ROI for top-down decision making? For decisions based on anecdotes and gut reactions?”

Joe didn’t have the answers, but he did have the ingredients to make a killer baked ziti. As Sally watched him walk to the kitchen, Penny pitter-pattering behind, she thought about the odds of changing Mark’s mind. At most institutions, it would be career suicide to confront the CEO about the flaws in his strategic plan. But Sally and Mark had been residents together, and he had personally recruited her for this position. If she played up the potential cost savings of EBMgmt, she might have a chance.

Unfortunately, as Harry pointed out, scientific proof of evidence-based management’s positive ROI did not exist — yet. She’d be taking a gamble by advocating for it so strongly. On the other hand, if they committed to Mark’s plan as is, they might never make any improvements at all in patient care.

Should Sally listen to Harry and slowly build her case for evidence-based management, or should she immediately launch a campaign to sell the CEO on the approach?