ORIGINAL ARTICLE

Building a culture of evidence-informed decision makingin the communityLindsay Campbell Peach, BSc, MHSA, CHE, and Elaine Rankin, RN, BACS, MES

Abstract—Growing fiscal pressures on health departments both provincially and locally necessitate tough decisions to bemade. Although evidence-informed decision making may be commonly used for clinical decision making, the notion ofevidence-informed decision making for managing physician office practice processes, primary care, long-term care, orcontinuing care is limited. In healthcare, much data are collected, yet only a small percentage is actually used in meaningfulways. The Executive Training for Research Application (EXTRA) program strives to not only assist healthcare executives inacquiring necessary skills but also aims to lead cultural change in the Canadian healthcare system. This article describes threebrief examples in which a vice president and director with EXTRA training have started to explore and use data to drivechange in the community.

Growing fiscal pressures on health departments bothprovincially and locally necessitate tough decisionsto be made. Often within and between divisions,

there are competing interests and priorities necessitatingdata to inform senior-management decisions. There areoften many sources of data that go unused, leaving someto wonder about the value of collecting data that may beunderused. Most data currently used to inform decisionmaking come from acute care–based sources, which maynot provide a complete picture. The absence of data fromother healthcare sectors or the underutilization of datathat may be in existence can be as important as theevidence.Although evidence-informed decision making may be

commonly used for clinical decision making, the notion ofevidence informed decision making for managing physi-cian office practice processes, primary care, long-term care,or continuing care is limited. As awareness increasesaround the need for using new or existing sources of datain all sectors of the health system to inform planning,innovation will be required. This article describes threebrief examples in which a vice president and director withThe Executive Training for Research Application (EXTRA)training1 have started to explore and use data in new anddifferent ways to drive change in the community. Fororganizations such as the Cape Breton District Health Au-thority who have participated in the EXTRA program, it is

From the Cape Breton District Health Authority, Cape Breton, Nova Scotia,Canada.

Corresponding author: Lindsay Campbell Peach, BSc, MHSA, CHE, Popu-lation Health and Continuing Care, Cape Breton District Health Authority,Cape Breton, P.O. Box 399, North Sydney, NS B2A 34M, Canada

(e-mail: peachl@cbdha.nshealth.ca).Healthcare Management Forum 2011 24:S17–S200840-4704/$ - see front matter© 2011 Canadian College of Health Leaders. Published by Elsevier Inc. Allrights reserved.

doi:10.1016/j.hcmf.2011.01.001

vital to transfer learnings from EXTRA to other internalorganizational leaders to champion system change.

EXAMPLE 1: ADVANCED ACCESS IN APRIMARY CARE SETTING

Advanced access was pioneered in the United States orig-inally but was later adopted, refined, and studied in theUnited Kingdom. At present, it is used extensively in theUnited States and is included in the Institute for HealthCare Improvement learning modules.2,3 Knowledge andlearnings have been translated into a Canadian contextand, as a result, the prevalence of advanced access isincreasing in Canada. The Saskatchewan Health QualityCouncil has recently embraced advanced access as a vitalpart of health quality and encourages practices provincewide to adopt these quality principles as part of its man-date.4 The literature clearly supports the benefits of ad-vanced access, acknowledging a successful change processdepends on the willingness and ability to create a sharedvision all office staff can follow (Dixon et al, 2004; Abbott etal, 2004).5

Emergency room managers within the Cape Breton Dis-trict Health Authority (CBDHA) are interested in advancedaccess because the majority of emergency room visits inthe district reflect Canadian Triage and Acuity Scale(CTAS) levels 4 and 5 (less urgent and non-urgent).Treating these patients in primary care settings canreduce some of the current workload stresses on emer-gency rooms. Potential same-day appointments mayeven prevent more serious emergency room visits andpossible admissions by treating sick patients sooner,thereby preventing more costly treatment.Although the wait times for a family physician office

appointment do not directly relate to emergency over-crowding, the appropriate use of emergency rooms cannotbe overlooked. From a family practice business model

perspective, patients attending emergency rooms for non-

Peach and Rankin

urgent needs can be viewed as lost revenue. From a qualityperspective, the continuity of care and patient safety maybe jeopardized because of fragmented care provided inemergency rooms. Finally, from a primary care perspective,the importance of access to the right provider at the righttime is of the upmost importance. Fundamentally, patientswould rather see their family physician than go to theemergency room.Hospital information technology allows for enhanced

quality reporting. However, the actual use of these datais most often confined to hospital-based reporting andmonitoring. The use of such hospital-based data to sup-port the provision and usage of quality monitoringwithin primary-care physician settings is limited. Histor-ically, evidence such as emergency room usage data isanalyzed poorly or not at all. During cohort 3 of EXTRA,the CBDHA actually used data that were collected buthad not been previously examined. Most specifically,emergency room triage data collected by family physi-cian were analyzed (Table 1). The potential for generalpractice physicians to use their own data to supportevidence-informed office-based decision making may beparamount to promote change.The overarching problem of access to family physician

services centres around improved office efficiencies to in-crease patient access to timely care. Although this is im-portant to the district from an emergency room perspec-tive and certainly from a health outcome perspective,family physicians for the most part work as independentpractitioners in the community. Physician involvementin quality initiatives tends to be voluntary and individ-ual. However, the issue of wait times for family physiciancare has become increasingly dominant on the provin-cial and national policy agenda. Based on the realities

Table 1. Sample emergency room patient visits level 4 and 5 CT

2008�2009 Weekday

Doctor0800�2359

hrs2400�0759

hrs Su

1 240 122 246 83 388 94 605 235 795 276 1181 47 17 1907 83 18 0 0

Totals 5362 209 5Average # of visits 766 30Standard deviation �/� 559 25

VLY, Versus Last Year.

presented previously, the EXTRA Advanced Access Inter-

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vention Project attempted to address the issue of timelyaccess to family physician office appointments by in-creasing awareness and implementation of advancedaccess principles.One Cape Breton family physician who had fully incor-

porated advanced access principles in his office practicewas anxious to measure the impact of change in order tostimulate interest from other family physicians. To theseends, a partnership with a Cape Breton University re-searcher was formed, and a research evaluation frameworkwas developed to measure the effect of advanced accesson this office practice.Research results included the following:

1. Emergency room visits: a 28% reduction in familyphysician patient emergency room visits triaged ac-cording to the CTAS at 4 and 5, a reduction in lostrevenue (triage 4 and 5 emergency room visits nowbeing seen in the office), a promotion of continuityof care (patients seen by family physician ratherthan emergency room doctors or walk-in clinicstaff), and an early presentation of illness dealtwith in a family physician practice rather than theemergency room.

2. Economic (physician office visit income): a 7% reve-nue increase after change (3-month period pre- andpost-change); fewer no shows (reduced lost income);efficient visits may provide increased opportunitiesfor chronic disease prevention/management (reve-nue generation); and staffing resources redirected tohigh-quality, efficient patient care instead of triagingappointments, handling patient complaints/con-cerns, and overuse of the telephone.

3. Economic (health system costs): although the system

y family physician

2009�2010 Weekday% Change

(VLY)

l0800�2359

hrs2400�0759

hrs Subtotal plus or minus

298 14 312 24%241 5 246 �3%355 18 373 �6%527 23 550 �12%934 22 956 16%

1206 34 1240 1%1678 53 1731 �13%171 6 177 0%

5410 175 5585 0%676 22 698 �12%508 15 522

AS b

btota

252254397628822228990

0571796584

level costs of an emergency room visit were not part

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BUILDING A CULTURE OF EVIDENCE-INFORMED DECISION MAKING IN THE COMMUNITY

of the initial advanced access research study, as theCBDHA tries to increase uptake of advanced access,other data sources have been used. With the imple-mentation of organizational electronic financial ac-counting systems, the ability to determine actualemergency room visit costs is now possible. In theCBDHA for the fiscal year 2009 to 2010, the cost of anaverage emergency room visit was $143.00. This in-cludes all direct costs ($115.78) and indirect costs($26.63).6 This amount does not include the physi-cian costs. This is almost 5 times more than a stan-dard office visit. It should be noted that, in NovaScotia, an office visit to a family physician costs ap-proximately $30.00. This translates to not only lostphysician revenue within an office setting but also tohuge system costs. In 2009 to 2010, there were45,265 emergency room visits triaged at level 4 and5 between Monday and Friday weekdays over a 24-hour period within all CBDHA facilities. This translatesinto over $6.4 million dollars.

EXAMPLE 2: ENHANCING PRIMARY CARE INLONG-TERM CARE SETTINGS

In Nova Scotia, the integration of long-term care and con-tinuing care within the responsibilities of the DistrictHealth Authorities is ongoing. Opportunities for new usesof evidence to inform planning are evolving. The additionof primary care nurse practitioners working with commu-nity physicians in these settings has had a tremendousimpact on quality of life issues for long-term care residents.Performance/improvement measurements include nursinghome residents able to die in their home (nursing home)and reduction in hospital admissions.Maple Hill Manor, a 50-bed facility located in New Wa-

terford, Cape Breton has a goal of no hospital deaths.7 TheManor often engages sitters or family for extra supportduring the end-of-life process. The addition of a nursepractitioner has facilitated palliative care patient needs toavoid death in hospital. This addition has also had a pos-

Table 2. Implementation Results of Nurse Practitioner in MapleHill Manor in 2008

Maple Hill Manor

Year Deaths in hospital Fiscal year Hospital admissions

006 6 2000 22007 5 2004 18008 1 2006 29009 1 2008 8010 2 2010 5

itive impact in reducing the number of hospital admis-

Healthcare Management Forum ● Forum Gestion des soins de s

sions, allowing long-term care residents to be cared for athome (Table 2).

EXAMPLE 3: A POPULATION HEALTH APPROACHTO FALLS PREVENTION

Monitoring and taking action to reduce falls within hospi-tals and nursing homes are a priority for district healthauthorities. Quality-based falls prevention committees areformed, and reporting processes are created and moni-tored. However, evidence for the Cape Breton Districtshows that the majority of falls actually occur at home andcost the system millions of dollars for injuries such as hipreplacements. Extended lengths of stays were also re-ported because of seniors waiting for long-term care place-ment as a result of such falls.Nova Scotia is fortunate to have a variety of provincial

programs that collect and house extensive data that can beused to plan and evaluate services and programs. A relevantexample is the Nova Scotia Trauma Registry Program, whichreports all ambulance trips within the province. Their datashows that the most common cause of injuries for CBDHAresidents are falls related.8 Interestingly, the data also showthat the majority of falls occur at home, and the correspond-ing costs to the health system are significant. A provincialstrategy for falls prevention using a population health ap-proach exists. However, the possibility of integration with thedistrict quality committee on falls prevention presents uniqueopportunities. The incorporation of Trauma Registry data in adistrict-wide falls prevention strategy may assist in enhanceddecision making and broad community-based action on fallsprevention.Other data to support a falls prevention strategy in-

cludes the following: (1) seniors (age 65�) bear a dispro-portionate burden of admissions/discharges as well asdeaths as hospitalization outcomes for falls, (2) within the65� age group, women experience a greater number ofadmissions/discharges than men, (3) within the 65� agegroup, those over 85 experience the largest number ofadmissions/discharges, (4) within the 65� age group, menexperience a greater number of deaths than females, and(5) within the 65� age group, those over 85 experience thelargest number of deaths.

CONCLUSION

These three examples show how data can inform practiceand programming in a community setting. Having a vicepresident and director in the same division who have EXTRAtraining affords innovative opportunities for advancing evi-dence-informed decision making and planning. In addition,having the ability to review all cohort projects from across thecountry and make links to assist with local thinking andplanning is invaluable. Monthly divisional meetings have the

opportunity to focus all departments on quality measure-

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Peach and Rankin

ment and innovation. EXTRA training provides a springboardfor innovative thinking and planning in which both the vicepresident and director instill the need for evidence-informeddecision making as a necessity to plan and deliver care.Continuous exploration of new applications for evidence-informed planning is required and can flourish under theexpertise and insight the EXTRA training provides.Increased emphasis on evidence-informed decision mak-

ing is required, yet there is also a need for improved reviewand use of data. A “reality check” is required to review whatdata districts and provincial programs collect and how oreven if they are used. Data collection duplication needs tobe avoided and balanced with the need for new andenhanced sources of data collection and application tosupport positive change in the community setting.

REFERENCES

1. EXTRA: Executive Training for Research Application (EXTRA).

Available at: www.chsrf.ca/extra. Accessed December 11, 2010.

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2. IHI, Institute for Healthcare Improvement. How to improveprimary care access. Available at: www.IHI.org. Accessed Octo-ber 25, 2010.

3. IHI, Institute For Healthcare Improvement. Advanced access: Reduc-ing waits, delays and frustration in Maine. Available at: http://www.ihi.org/IHI/Topics/OfficePractices/Access/ImprovementStories/AdvancedAccessReducingWaitsDelaysandFrustrationinMaine.htm.Accessed October 25, 2010.

4. Saskatchewan Health Quality Control. Available at: www.hqc.sk.ca. Accessed September 7, 2010.

5. Dixon S, O’Cathain A, Pickin DM, et al. Evaluation of advancedaccess in the national primary care collaborative. Br J Gen Pract.2004;54:334–340.

6. Email Communication, (CBDHA Chief Financial Officer August17, 2010).

7. Personal Communication, (Director of Resident Care, Maple HillManor New Waterford, N.S. August 27, 2009).

8. Nova Scotia Trauma Registry Data Request Received March 3,2009. Nova Scotia Trauma Program 1276 South Park Street,Centennial Building Room 1-026B Halifax, Nova Scotia B3H

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