Posted by: Knightbird | September 1, 2013

“Evidence Based” and “Best Practice”

I see both phrases used often in the social sciences and healthcare. One definition I found about evidenced based practices (EBP) states: “EBP is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ ” (Sackett D, 1996). A best practice has been defined as “a method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark.”

Yet the context in which I typically see EBP advocated for use in an organization is a statement that the tool or technique must be used because it has been proven to be the best way to do things. It is akin to a BP. So it often seems that we advocate using a best practice because it is evidence based and we must benchmark our results against that best practice. In other words, we must learn from others through their best practices that have achieved excellent results for them. And how do we learn about the best practice? We hire consultants, of course.

The consultants then come in and teach us how to do something. I have seen many examples of this. For a period of time at an Alaska Native health organization, I kept hearing about rounding and thank you letters. I blogged about this before. The practice did not lead to world class result, and employees resented it. Why? Probably because it added no value to the processes they were introduced to.

A second example involved a significant commitment of time by my staff to implementing a specific process as a best practice. We left the group after a short period of time because we were learning nothing. Other groups had to go through the learning a couple of times because it didn’t really resonate with their employees.

Yet both efforts took huge resources including employee time and money.

What did I do instead? You guessed it-Lean Thinking. The consultant led efforts told employees what to do, how to do it and when to do it. And none of the advice was based on the unique circumstances and structure of the client’s specific process. They were told that emulating this best practice would achieve great results for them. And they did not.

A lean practitioner does learn from best practices. That’s what the Toyota Production System is, an organization’s learning based upon what was successful at other organizations. Toyota took its flow concepts from Henry Ford. Just in Time was influenced by the Piggly Wiggly inventory management system. Takt Time came through Junkers Aircraft in Germany that found its way to Japan and manufacture of aircraft by Mitsubishi. Training at Toyota came from the Training within Industry protocol developed in the United States and used during World War II. And of course, one cannot dismiss the tremendous influence of Dr. Deming on the mechanism of continuous improvement through control charts and the PDSA cycle, among many others.

My point is that best practices and evidenced based practices are a big help. They give us insight into what has worked elsewhere and that can advance our learning tremendously. But it has to be our learning. It has to go into our system and our system, whoever and wherever you are, is unique to our circumstances. Our health care practice management needs to reflect our resources, our people and our customers. When we use lean thinking by teaching it to our employees, we don’t order them to adopt a best practice or evidence based practice. We teach them about it, and talk about what the practice might add to the way we deliver value to our patients, clients or customers. We use the culture of lean to focus on the needs of our customers and respect the desire of our employees to deliver value to the customers. We connect the 2 by the tools of lean, and we should always be willing to add new learning to our toolbox of knowledge. But should we adopt something because it is EBP or BP? I say no. We are unique, and EBP and BP should be added to our knowledge so we become better able to value our customers and employees.

When you hire a Lean Sensei as a consultant, it should not be for the purpose of introducing a specific practice. It should be for the purpose of changing your management culture. A good Sensei will teach you the strategic value of Lean. You will learn the tools of lean at the same time as you are learning about respect for your customers, partners and employees. Then when you write a letter or note to an employee thanking him or her for their good work, it will have meaning because you understand all that employee did to deliver value to your customer. When you design services to fit your customer, it will be based on information you got directly from the customer while you were “rounding.” When you are improving customer flow through your clinic, it will be based on a solid grounding on what promotes flow based on an understanding of demand you gain from analysis involving Takt time. And your goal will be to deliver quality services to your customer when they need it, where they need it, and in the appropriate quantity-nothing more, nothing less.

EBP and BP are important. Toyota learned from both, but integrated them into a management system that continues to grow and learn. You should do the same. The process of continuous improvement will incorporate EBP and BP until something better comes along.


  1. “[Rounding and thank you letters] did not lead to world class result, and employees resented it. Why? Probably because it added no value to the processes they were introduced to.”

    It could also be a number of things that led to that:

    1) Employees weren’t involved in the process of identifying a problem and developing a countermeasure. They were told to just do the best practice.

    Rounding is a great countermeasure to problems of patient falls, low patient satisfaction, etc. I’m sure the thank you notes don’t really solve a problem, but are probably found to boost patient satisfaction (which, to me, seems very superficial when we have patients being HARMED by hospitals).

    2) Employees weren’t told why these methods were important or how these methods help.

    As Ohno said, a person must first learn “why” before they learn “how.”

    Thanks for your reflections!!

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