In the present study, a comprehensive framework for EBDM in HSM was developed. This model has different distinguishing characteristics than the formers. First of all, this is a comprehensive practical model that combined the strengths and the crucial components of the previous models; second, the model includes more details and complementary steps and sub-steps for full implementation of EBDM in health organizations and finally, the model is benefitted from a cyclic nature that has a priority than the linear models. Concerning the differences between the present framework and other previous models in this field, it must be said that most of the previous models related to EBDM were presented in the scope of medicine (that they were excluded from our SR according to the study objectives and exclusion criteria). A significant number of those models were proposed for the scope of public health and evidence-based practice, and only a limited number of them focused exactly on the scope of management and policy/decision making in health system organizations.
Furthermore, based on the findings from SR, most of the previous studies only referred to some parts of the components and steps of the EBDM in health organizations and neglected the other parts or they were not sufficiently comprehensive (34–43). Most of the previous models did not mention the necessary sub-steps, tools, and practical details for accurate and complete implementation of the EBDM, which causes the organizations that want to use these models, will be confused and cannot fully implement and complete the EBDM cycle. Among the studies that have provided a partly complete model than the other studies, were the studies by Brownson (1999), Rosswurm (1999), Brownson (2009), Yost (2014), and Janati (2018) (3,4,32,44,45). Consequently, the combination of these five studies has been used as the initial framework for the best-fit synthesis.
Likewise, the models presented by Brownson (1999), Brownson (2009), 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 doing in each of the steps, too (3,4,45). 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 (32,45); however, the model presented in this study was recursive. Also, in Yost's study (2014), despite the 7 main steps of EBDM and some details of each of the steps, the proposed process was not schematically drawn in the form of a framework and therefore the relationships between steps and sub-steps were not clear (44). According to what was discussed, the best-fit framework makes the possibility of concentrating the fragmented models to a comprehensive one that can be fully applied and evaluated by the health systems policymakers and managers.
In the present study, the framework of EBDM in HSM was developed in the form of four general scopes of inquiring, inspecting, implementing, and integrating including 10 main steps and 56 sub-steps. These scopes were discussed as follows:
Inquiring
In the first step, “situation analysis and priority setting”, the most frequently cited sub-step was the identification of the problem. Accordingly, Falzer (2009), emphasized the importance of identifying the decision-making conditions and the relevant institutions and determining their dependencies as the first steps of EBDM (46). Aas (2012) has also cited the assessment of individuals and problem status and problem-finding as the first steps of EBDM (37). 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 in strategic planning (47).
Despite considering the opinions and experience of experts and managers as one of the important sources of evidence for decision-making (45,48–52), 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” was addressed more than others (38,40,44,49). In addition, the authors to complete this step added the fourth sub-step, “Defining the main statement of issue”. This is because that most of the problems in health settings 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”, was 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 essential structures and infrastructures have been identified as facilitators of EBDM (53–57). 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” (49,50,58), “gaining the support and commitment of leaders” (49,59–61), and “identifying the capabilities required by employees and their skills weaknesses” (61–64) were 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 (35). 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" was important (58).
The present findings showed that in the fourth main step, “evidence acquisition and integration”, the most important sub-step was “finding the sources for seeking the evidence” (32,42–44,51,59,61). 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 (42,65,66). After scientific evidence, using the opinions and experiences of experts, colleagues, and managers (45,48,51,60) as well as the use of census and local level data (51,60,67), and other sources such as financial (67), political (45,51) and evaluations (51,68) data were cited.
Inspecting
The fifth step of the present framework, “evidence appraising”, was emphasized by previous literature; for instance, Pierson (2012) pointed to the use of library services in EBDM (69). In this step, the sub-step of “evaluation and selection of pieces of evidence based on benefits and risks data, feasibility, applicability, and transparency” was cited the most. International and local evidence is confirmed that ignoring these criteria can lead to serious faults in the process of decision and policy-making (70,71).
Furthermore, the sixth step, “analysis, synthesis, and interpretation of data”, was mentioned in many included studies (35,38,46,49,72). 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 achieving 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 the 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 had been focused by the previous studies (51,56,72,73). Studies by Belay (2009) and Armstrong (2014) had also emphasized the need to use stakeholder and public opinion as well as local and demographic data in decision-making (51,67).
“Pilot-implementation of selected alternatives” was the eighth step of the framework. The key sub-step of this step was “Pre-implementation and pilot change in practice” (32,34,43,59) that indicated 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 many 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 been recommended in public health in cases of lack of sufficient evidence (74).
Integrating
This last scope consists of the ninth and tenth steps. The main sub-step of the ninth step, “evaluating alternatives”, was to evaluate the implementation process and the resulting outputs. After a successful implementation of the pilot, this step can be assured that the probable outcomes may be achieved and this evaluation will help the decision and policymakers to control the outcomes, effectively. 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 (57).
Also, the tenth step, “integrating and maintaining change in practice”, was 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 several 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 (38). Finally, the most important sub-steps that could be mentioned in this step were the “dissemination of evidence results to decision-makers” and the “integration of changes made to existing standards and performance guidelines”. Liang (2012) had also emphasized the importance of translating existing evidence into useful practices as well as disseminating them (49). In addition, the final sub-step, “feedback and feedforward towards the EBDM framework”, was explained by the authors to complete the framework.
Some previous 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 (75). The results of a study conducted on healthcare managers at the various levels of an Iranian largest medical university showed that the status of EBDM is not appropriate. This problem was more evident among physicians who have been appointed as managers and who have less managerial and systemic attitudes (76). Such studies, by concerning the shortcomings of current models for EBDM in HSM or even lack of a suitable and usable one, have confirmed the necessity of developing a comprehensive framework or model as a practical guide in this field. Consequently, existing and presenting such a framework can help to institutionalize the concept of EBDM in health organizations.
In contrast, results of Lavis study (2008) 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 evidence in their process of decision-making (75), 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 that we tried to access them by manual searching and asking from some articles’ authors and experts. 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. Consequently, we tried to search for studies from various databases and carefully review and screen them to make sure that we did not lose any relevant data and thematic code. Also, instead of one model, we used four existing models as a basis in the BFF synthesis so that we can finally, by adding additional codes and themes obtained from other studies as well as expert opinions, provide a comprehensive model taking into account all the required steps and details. Also, the framework developed in this study is a complete conceptual model made by the SR of studies using the BFF synthesis; however, it may need some localization, according to the status and structure of each health system, for applying it.