1. Evidence-Based Practice
Sioo, 8 april 2013
Utrecht

2. Evidence-based practice
 Wat is het?
 Waar komt het vandaan?
 Hoe ziet het er uit in een opleiding?

3. Evidence based practice:
Wat is het?

4. Definition
Evidence based practice:
Improve information to support decision making

5. Evidence-based practice
Uitgangspunt bij evidence-based practice is
dat beslissingen gebaseerd dienen te zijn
op een combinatie van kritisch denken en
de best beschikbare 'evidence'.

6. Evidence based practice
Met het begrip 'evidence' wordt niet
meer bedoeld dan 'informatie'.
Dit kan informatie zijn afkomstig uit
wetenschappelijk onderzoek, maar ook
interne bedrijfsinformatie en persoonlijke
ervaring geldt als 'evidence’.

7. Evidence based practice
In principe neemt iedere manager dus
beslissingen op basis van 'evidence'.
De meeste managers besteden echter
nauwelijks aandacht aan de kwaliteit
van de 'evidence' waarop ze hun
beslissingen baseren.

8. Evidence-based practice:
 kritisch denken
 van verschillende informatiebronnen
gebruik maken >> best available evidence?
 de evidence kritisch tegen het licht houden
 denken in termen van waarschijnlijkheid
in plaats van 'golden bullets'.

9. Evidence based practice
Best available Professional
external evidence expertise and
judgment
Evidence-based
decision
Best available Stakeholders’
internal evidence values and concerns

10. Evidence based practice:
Waar komt het vandaan?

11. What field is this?
 “there is a large research-user gap”
 “practitioners do not read academic journals”
 “the findings of research into what is an effective intervention
are not being translated into actual practice”
 “academics not practitioners are driving the research agenda”
 “the relevance, quality and applicability of research is
questionable”
 “practice is being driven more by fads and fashions than
research”
 “many practices are doing more harm than good”

12. Medicine: Founding fathers
David Sackett Gordon Guyatt
McMaster University Medical School, Canada

13. How it all started

14. Problem I: persistent convictions
if you’re
breathe into a bag
hyperventilating

15. Problem I: persistent convictions
elderly people who have give them a drug that
an irregular heartbeat are reduces the
much more likely to die of number of
coronary disease irregular beats

16. How 40,000 cardiologists can be wrong
In the early 1980s newly introduced
anti-arrhythmic drugs were found to be
highly successful at suppressing
arrhythmias.
Not until a RCT was performed was it
realized that, although these drugs
suppressed arrhythmias, they actually
increased mortality.
By the time the results of this trial were
published, at least 100,000 such
patients had been taking these drugs.

17. Problem II: too much information
 More than 1 million articles in 40,000 medical journals per
year (= 1995; now probably more than 2 million). For a
specialist to keep up this means reading 25 articles every
day (for a GP more than 100!)

18. Problem I: persistent convictions
Maslow, A.H. (1943). "A Theory of Human Motivation," Psychological Review 50(4)
Wahba, M. A., & Bridwell, L. G. (1976). Maslow reconsidered: A review of
research on the need hierarchy theory. Organizational Behavior and Human
Performance, 15(2)

19. True or false?
1. Incompetent people benefit more from feedback than
highly competent people.
2. Task conflict improves work group performance while
relational conflict harms it.
3. Encouraging employees to participate in decision
making is more effective for improving organizational
performance than setting performance goals.

20. How evidence-based are we?
HR Professionals' beliefs about effective human resource practices: correspondence
between research and practice, (Rynes et al, 2002, Sanders et al 2008)
 959 (US) + 626 (Dutch) HR professionals
 35 statements, based on an extensive body of evidence
 true / false / uncertain
On average: 35% - 57% correct

21. Problem II: too much information
 HRM: 1,350 articles in 2010 (ABI/INFORM). For an HR
manager to keep up this means reading 3 to 4 articles
every day (for a „general‟ manager more than 50!)
BTW: most of the research is seriously
flawed or irrelevant for practice

22. David Sackett
 Half of what you learn in medical school will be
shown to be either dead wrong or out-of-date
within 5 years of your graduation; the trouble is that
nobody can tell you which half.
 The most important thing to learn is how to learn
on your own: search for the evidence!
 (Remember that your teachers are as full of bullshit
as your parents)

23. The 5 steps EBP: pull approach
1. Formulate a focused question (Ask)
2. Search for the best available evidence (Acquire)
3. Critically appraise the evidence (Appraise)
4. Integrate the evidence with your professional
expertise and apply (Apply)
5. Monitor the outcome (Assess)

24. Evidence-Based Practice
1991 Medicine
1998 Education
1999 Social care, public policy
2000 Nursing
2000 Criminal justice
???? Management?

25. Evidence based practice:
Hoe ziet het er uit in de opleiding?

26. Evidence-based practice
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk
denken dat leidt tot een professioneel-kritische attitude met
betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en
op basis van deze vraag kunnen zoeken in online databases
naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van
wetenschappelijke en organizational evidence (critical
appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen
toepassen in de eigen beroepspraktijk (application of science)

27. Evidence based practice
Best available Professional
scientific evidence expertise and
judgment
Evidence-based
decision
Best available Stakeholders’
organizational
values and concerns
evidence

28. Trust me, 20 years of experience

29. Bounded rationality

30. Bounded rationality

31. Het feilbare brein
System 1
 Snel, actie
 Intuitief, associatief
 shortcuts & biasses
System 2
 Langzaam (lui!)
 Rationeel
 Nadenken

32. Bounded rationality
neo cortex
(systeem 2)
limbische systeem
en hersenstam
(systeem 1)

33. Systeem 1

34. Systeem 1: het feilbare brein
 Seeing order in randomness
 Mental corner cutting
 Misinterpretation of incomplete data
 Halo effect
 False consensus effect
 Group think  Confirmation bias
 Self serving bias  Authority bias
 Sunk cost fallacy  Small numbers fallacy
 Cognitive dissonance reduction  In-group bias
 Recall bias
 Anchoring bias
 Inaccurate covariation detection
 Distortions due to plausibility

35. Fase 1: Kritisch & wetenschappelijk denken
1. Denkfouten
2. Informatiebronnen
3. Mythbusting
4. Assumpties

36. Richard Feynman
“The first principle is that you must not fool
yourself - and you are the easiest person to
fool”.

37. Seeing order in randomness
 Een Type I fout of een vals positief:
denken dat er een patroon / verband is
terwijl dat er in het echt niet is.
 Een Type II fout of een vals negatief:
denken dat er geen patroon / verband is
terwijl dat er in het echt wel is
Dr. Michael Shermer
(Director of the Skeptics Society)

38. Het feilbare brein: patern recognition
 Een Type I fout of een vals positief: denken dat het
geritsel in de bosjes een gevaarlijk roofdier is, terwijl
het gewoon de wind is (goedkoop foutje)

39. Het feilbare brein: patern recognition
 Een Type II fout of een vals negatief: denken dat het
geritsel in de bosjes gewoon de wind is, terwijl het een
gevaarlijk roofdier is (duur foutje)

40. Het feilbare brein: patern recognition
 Een Type I fout of een vals positief: denken dat het
geritsel in de bosjes een gevaarlijk roofdier is, terwijl
het gewoon de wind is (goedkoop foutje)
 Een Type II fout of een vals negatief: denken dat het
geritsel in de bosjes gewoon de wind is, terwijl het een
gevaarlijk roofdier is (duur foutje)

41. Het feilbare brein: patern recognition
Ook ervaren mensen en experts zien patronen
en verbanden waar ze niet zijn.
stress & lifestyle peptic ulcer

42. Oct 2005
Peptic ulcer – an infectious disease!
This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin
Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By
using technologies generally available (fibre endoscopy, silver staining of
histological sections and culture techniques for microaerophilic bacteria), they
made an irrefutable case that the bacterium Helicobacter pylori is causing disease.
By culturing the bacteria they made them amenable to scientific study.
In 1982, when this bacterium was discovered by Marshall and Warren, stress and
lifestyle were considered the major causes of peptic ulcer disease. It is now
firmly established that Helicobacter pylori
causes more then 90% of duodenal ulcers.
The link between Helicobacter pylori
infection and peptic ulcer disease has been
established through studies of human
volunteers, antibiotic treatment studies and
epidemiological studies.

43. Errors and Biases of Human Judgment
superstitious superstitious
rituals rituals
more stress = more prone to biases

44. Errors and Biases of Human Judgment

47. Beliefs vs Evidence
“What gets us into trouble is not what we
don't know,
it's what we know for sure that just isn't so.”
Mark Twain

48. Het feilbare brein: patern recognition
Ook slimme mensen houden er verkeerde ideeën op
na, niet omdat ze dom of eigenwijs zijn, maar omdat het
de meest logische conclusie is op basis van hun eigen
ervaringen.
(systeem 1 doet altijd mee!)

49. Evidence-based practice
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk
denken dat leidt tot een professioneel-kritische attitude met
betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en
op basis van deze vraag kunnen zoeken in online databases
naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van
wetenschappelijke en organizational evidence (critical
appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen
toepassen in de eigen beroepspraktijk (application of science)

51. The 5 steps EBP
1. Formulate a focused question (Ask)
2. Search for the best available evidence (Acquire)
3. Critically appraise the evidence (Appraise)
4. Integrate the evidence with your professional
expertise and apply (Apply)
5. Monitor the outcome (Assess)

52. Formulate a focused question

53. Focused question?
 Does team-building work?
 What are the costs and benefits of self-steering teams?
 What are the success factors for culture change?
 Does management development improve the
performance of managers?
 Does employee participation prevent resistance to
change?
 How do employees feel about 360 degree feedback?

54. Foreground question?
 Does team-building work?
 What is a „team‟?
 What kind of teams?
 In what contexts/settings?
 What counts as „team-building‟?
 What does „work‟ mean?
 What outcomes are relevant?
 Over what time periods?

55. Answerable question: PICOC
P = Population
I = Intervention or success factor
C = Comparison
O = Outcome
C = Context

56. 2. Finding the best available evidence

57. Searching evidence
What do we search?

58. What do we search?
Current Information
Overview of a subject
General background
Academic Information
Statistical Information
Theories about a subject
Company information

59. Peer reviewed journals

60. Searching for evidence

61. Databases
 ABI/INFORM
 Business Source Elite
 PsycINFO
 Web of Knowledge
 ERIC
 Google Scholar

62. Searching for evidence

63. Searching evidence
How do we search?
Search Strategy

64. Search strategy
Two types of search strategies
Snowball method Building blocks method

65. Search strategy

66. Hands on instruction

67. Example: merger

68. Question
Imagine you are a consultant, your client is the board of
directors of a large Canadian health-care organization.
The board of directors has plans for a merger with a
smaller healthcare organization in a nearby town.
However, it‟s been said that the organizational culture
differs widely between the two organizations. The board
of directors asks you if this culture-difference can impede
a successful outcome of a merger. Most of them
intuitively sense that cultural differences matter, but they
want an evidence-based advice.

69. Answerable question: PICOC
What else would you like to know?

70. Answerable question: PICOC
P: What kind of Population are we talking about? Middle managers,
back-office employees, medical staff, clerical staff?
O: What kind of Outcome are we aiming for? Employee productivity,
return on investment, profit margin, competitive position, innovation
power, market share, customer satisfaction?
P/C: And how is the assumed cultural difference assessed? Is it the
personal view of some managers or is it measured by a validated
instrument?

71. Answerable question: PICOC
According to the board the objective of the merger is to
integrate the back-office of the two organizations (ICT,
finance, purchasing, facilities, personnel administration,
etc.) in order to create economy of scale. The front
offices and primary process of the two organizations will
remain separate.
The cultural difference is not objectively assessed (it is
the perception of the senior managers of both
organizations).

72. Answerable question: PICOC
P = back office employees in a healthcare organisation
I = merger, integration back office
C = status quo
O = economy of scale
C = different organizational culture, unequal

78. Evidence-based practice
Fase 1: Het ontwikkelen van kritisch en wetenschappelijk
denken dat leidt tot een professioneel-kritische attitude met
betrekking tot organisatievraagstukken
Fase 2: Het kunnen formuleren van een expliciete vraag en
op basis van deze vraag kunnen zoeken in online databases
naar uitkomst van relevant wetenschappelijk onderzoek.
Fase 3: Het kritisch kunnen beoordelen van
wetenschappelijke en organizational evidence (critical
appraisal)
Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen
toepassen in de eigen beroepspraktijk (application of science)

80. What is the best research design?
 Randomized controlled study?
 Grounded theory approach?
 Cohort / panel study?
 Qualitative field research?
 Longitudinal study?
 Post-test only study?
 Survey?
 Action research?
 Case study?

81. What is the best design?
quants vs quallies, positivists vs post structuralist, etc

82. What is the BEST car?

84. Research designs
Which design for which question?

85. Effect vs Non-effect

86. Types of questions
Does it work?
Does it work better than ....?
Does it have an effect on ....?
Effect
What is the success factor for ....?
What is required to make it work ...?
Will it do more good than harm?

87. Types of questions: non-effect
Needs: What do people want or need?
Attitude: What do people think or feel?
Experience: What are peoples’ experiences?
Prevalence: How many / often do people / organizations ...?
Procedure: How can we implement ...?
Process: How does it work?
Explanation: Why does it work?
Economics: How much does it cost?

88. Internal validity

89. Internal validity
internal validity = indicates to what extent the
results of the research may be biased and is thus
a comment on the degree to which alternative
explanations for the outcome found are possible.

91. Causal relations
We are pattern seeking primates:
we are predisposed to see order
and causal relations in the world

92. Causality
When do we know there is a causal relation?
1. Are the "cause" and the "effect” related?
measurements, effect size
1. Does the "cause" precede the "effect" in time?
before and after measurement
2. Are there no plausible alternative explanations for
the observed effect?
randomization, control group

93. Bias & Confounding
Research shows:
Shoe size > quality of handwriting
Smoking youngsters > better lung function

94. Levels of internal validity

95. Which design for which question?
Explanation

96. Different types of research questions
require different types of research designs,
but ...

97. Best research design?

99. Step 3: Critical appraisal of studies

100. How to read a research article?

101. Critical appraisal: quick and dirty
Is the study design appropriate to the stated
aims?
Are the measurements likely to be valid and
reliable?
Was there a relevant effect size?
Is the outcome (population, type of organization)
generalizable to your situation?

102. Appraisal
Critical appraisal questionnaires
www.cebma.org/ebp-tools

103. Aantal te laat betalers neemt toe
Best available Professional
scientific evidence expertise and
judgment
Evidence-based
decision
Best available Stakeholders’
organizational
values and concerns
evidence

105. CAT: Critically Appraised Topic

106. CAT: structure
1) Background / context
2) Question (PICOC)
3) Search strategy
4) Results / evidence summary max 3 pag.
5) Findings
6) Limitations
7) Recommendation

107. CAT-walk