The present study indicates a framework of EBDM in HSM; in this regard, after a SSR of existing studies, based on the most complete models and frameworks presented and published so far, a comprehensive framework of EBDM in HSM is provided using the BFF approach. The BFF synthesis has this potential value for systematic reviewers because they no longer need to review heavy texts, consultations, or expertise in supposed subject to create a basic framework before starting their systematic review. That is, based on the review itself, they can select a suitable baseline model and extend the analysis (31).
Based on the present findings, most of the previous studies only referred to some part of the components and steps of the EBDM in HSM and neglected the other parts or they were not sufficiently comprehensive (37–46). However, the findings of each previous study completed some parts of the framework which presented in this study. Among the studies that have provided a more complete model than the other studies, are the studies by Brownson (1999), Rosswurm (1999), Brownson (2009), Yost (2014), Wahabi (2015), and Janati (2018) (3,4,35,47–49). It should be noted that the combination of these six studies has been used as the initial framework for the best-fit synthesis.
Likewise, the models presented by Brownson (1999), Brownson (2009), Wahabi (2015), and Janati (2018) were only limited to the six or seven key steps of the EBDM process, and they did not mention the details required for each of the steps, too (3,4,48,49). Also, the models presented in the study of Rosswurm (1999) and Janati (2018) were linear, and the relationships between the EBDM components were not well considered (35,49); however, the model presented in this study is recursive. Also, in Yost study (2014), despite the 7 main steps of EBDM and some details of each of the steps, the framework presented was not schematically drawn and therefore the relationships between steps and sub-steps were not clear (47).
In the present study, the framework of EBDM in HSM is developed in the form of four general scopes of inquiring, inspecting, implementing and integrating including 10 main steps and 56 sub-steps. These scopes are discussed as follows:
Inquiring
In the first step, “situation analysis and priority setting”, the most frequently cited sub-step is the identification of the problem. Accordingly, Falzer (2009), emphasized the importance of identifying the decision-making conditions and also the relevant institutions and determined their dependencies as the first steps of EBDM (50). Aas (2012) has also cited the assessment of individuals and problem status and problem-finding as the first steps of EBDM (40). Moreover, the necessity of identifying the existing situation and issues and prioritizing them has been emphasized as the initial steps in most management models such as environmental analysis for strategic planning (51).
In spite of considering the opinions and experience of experts and managers as one of the important sources of evidence for decision-making (49,52–56), many studies, did not mention this sub-step in the EBDM framework. Hence, the present authors added the acquisition of experts’ opinions as a sub-step of the first step because of its important role in achieving a comprehensive view of the overall situation.
In the second step, “quantifying the issue and developing a statement”, “Developing the conceptual model for the issue” is addressed more than others (41,43,47,53). Also, the fourth sub-step, “Defining the main statement of issue” is added by the authors to complete this step. This is because of that most of the problems in health setting may have a similar value for managers and decision makers and quantifying them can be used as a criterion for more attention or selecting the problem as the main issue to solve.
The third step, “Capacity building and setting objectives”, is not seen in any other included studies as a main step in EBDM, however the present authors include this step because without considering the appropriate objectives and preparing necessary capacities and infrastructures, entering to the next steps may become problematic. Moreover, in numerous studies, factors such as knowledge and skills of human resources, training and the availability of the necessary structures and infrastructures have been identified as facilitators of EBDM (57–61). According to this justification, they are included in the present framework as sub-steps of the third step.
Considering the third step and based on the knowledge extracted from the previous studies, the three sub-steps of “understanding context and Building Culture” (53,54,62), “gaining the support and commitment of leaders” (53,63–65), and “identifying the capabilities required by employees and their skills weaknesses” (65–68) are the most important sub-steps in this step of EBDM framework. In this regard, Dobrow (2004) has also stated that the two essential components of any EBDM are the evidence and context of its use (38). Furthermore, Isfeedvajani (2018) stated that to overcome barriers and persuade hospital managers and committees to apply evidence-based management and decision-making, first and foremost, creating and promoting a culture of "learning through research" is important (62).
The present findings showed that in the fourth main step, “evidence acquisition and integration”, the most important sub-step is “finding the sources for seeking the evidence” (35,45–47,55,63,65). Concerning the sources for the use of evidence in decision-making in HSM, studies have cited numerous sources, most notably scientific and specialized evidence such as research, articles, academic reports, published texts, books, and clinical guidelines (45,69,70). After scientific evidences, using the opinions and experiences of experts, colleagues, and managers (49,52,55,64) as well as the use of census and local level data (55,64,71), and other sources such as financial (71), political (49,55) and evaluations (55,72) data were cited.
Inspecting
The fifth step of the present framework, “evidence appraising”, is emphasized by many literatures; for instance, Pierson (2012) pointed to the use of library services in EBDM (73). In this step, the sub-step of “evaluation and selection of pieces of evidence based on benefits and risks data, feasibility, applicability, and transparency” is cited the most. International and local evidences are confirmed that ignoring these criteria can lead to serious faults in the process of decision and policy making (74,75).
The sixth step, “analysis, synthesis, and interpretation of data”, is mentioned in many included studies (38,41,50,53,76). This step emphasized the role of analysis and synthesis of data in the process of generation applied and useful information. It is obvious that the local interpretation according to different contexts may lead to achieve such kind of knowledge that can be used as a basis for local EBDM in HSM.
Implementing
The third scope consisted of the seventh and eighth steps of EBDM process in HSM. In the seventh step, “developing evidence-based alternatives”, the issue of involving stakeholders in decision-making and subsequently, planning to design and implementation of the process and evaluation strategies has been the focus of previous studies (55,60,76,77). Studies by Belay (2009) and Armstrong (2014) have also emphasized the need to use stakeholder and public opinion as well as local and demographic data in decision-making (55,71).
“Pilot-implementation of selected alternatives” is the eighth step of the framework. The key sub-steps of this step is “Pre-implementation and pilot change in practice” (35,37,46,63) that indicates the significance of testing the strategies in a pilot stage as a pre- requisition of implementing the whole alternatives. It is obvious that without attention to the pilot stage, adverse and unpleasant outcomes may occur that their correction process imposes much financial, organizational and human costs on the originations. In addition, a study explained that one of the strategies of the decision-makers to measure the feasibility of the policy options was piloting them which had a higher chance of being approved by the policymakers. Also, pilot implementation in smaller scales has also been recommended in public health in cases of lack of sufficient evidence (78).
Integrating
This last scope consists of the ninth and tenth steps. The main sub-step of the ninth step, “evaluating alternatives”, is to evaluate the implementation process and the resulting outputs. This sub-step after a successful implementation of the pilot can be assuring that the probable outcomes may be achieved and this evaluation will help the decision and policy makers to control the final outcomes. Also, it impacts the whole target program and proposes some correcting plans through an accurate feedback process, too. Pagoto (2007) explained that a facilitator for EBDM would be an efficient and user-friendly system to assess utilization, outcomes, and perceived benefits (61).
Also, the tenth step, “integrating and maintaining change in practice”, is not considered as a major step in previous models, too, while it is important to maintain and sustain positive changes in organizational performance. In this regard, Ward (2011) also suggested a number of steps to maintain and sustain the widespread changes in the organization, including increasing the urgency and speed of action, forming a team, getting the right vision, negotiating for buy-in, empowerment, short-term success, not giving up and help to make a change stick (41). Finally, the most important sub-steps that can be mentioned in this step are the “dissemination of evidence results to decision makers” and the “integration of changes made to existing standards and performance guidelines”. Liang (2012) has also emphasized the importance of translating existing evidence into useful practices as well as disseminating them (53). In addition, the final sub-step, “feedback and feedforward towards the EBDM framework”, is explained by the authors to complete the framework.
In addition to what is discussed separately in each of the present framework’s scopes and steps, this ten-step framework can give a comprehensive view of a whole model to use evidences for decision-making in HSM. However, it seems that the applicability of the framework in different settings may be assured through future quantitative and qualitative studies. Also, as the other studies confirmed, such a framework has some potential benefits as follows; a deep understanding of improved ability to categorize and select information, engage with customers more closely and pay closer attention to their experiences, learning about critical thinking, improving self-efficacy and cognitive skills (79), gaining knowledge of new topics and applying them, making informed decisions, adapting interventions to community needs, communicating better with colleagues, making rational policy changes, educating others on how to use and apply evidence-based public health information, identifying and comparing costs and benefits of a plan or policy, preparing policy briefing for executives or provincial or local legislators, better funding for programs (80), effective performance, efficiency, transparency and accountability in decision-making and employee empowerment (81).
Considering these potential benefits, it seems that although many organizations specially those situated in under developed and developing countries may not apply such these frameworks in their process of decision and policy making, existing and presenting the framework can help the institutionalizing the concept of EBDM. For instance, some findings showed that about half and two-thirds of organizations do not regularly collect related data about the use of evidence, and they do not systematically evaluate the usefulness or impact of evidence use on interventions and decisions (82). In addition, the results of a study conducted on healthcare managers at the various levels of one of Iranian largest medical universities showed that the current state of EBDM is not appropriate. This problem is more evident among physicians who have been appointed as managers and who have less managerial and systemic attitudes (83). Such studies, given the shortcomings of current models for EBDM in HSM, have confirmed the necessity of developing a comprehensive framework or model as a practical guide in this field.
In contrast, results of Lavis (2008) study on organizations that supported the use of research evidence in decision-making reported that more than half of the organizations (especially institutions of health technology assessment agencies) may use the evidences in their process of decision making, so applying the present framework for these organizations can be recommended, too.
Limitations
One of the limitations of the present study was the lack of access to some studies (especially gray literature) related to the subject in question. In addition, most of the existing studies on EBDM were limited to examining and presenting results on influencing, facilitating or hindering factors, or they only mentioned a few components in this area. It should be noted that the framework developed in this study is a conceptual model made by the SSR of studies using the BFF synthesis of existing models; however, it needs validation and localization for making an instrument and using it in countries' health systems.