Evidence-based
Latest practice and patient-centered care Doing both well Ryann L. Engle
Feature
Evidence-based practice and patient-centered care:
Doing both well
Ryann L. Engle • David C. Mohr • Sally K. Holmes • Marjorie Nealon Seibert • Melissa Afable • Jenniffer Leyson • Mark Meterko
Background: Health care organizations increasingly strive to deliver care that is both evidence based and patient centered.
Although often complementary, fundamental contradictions may exist between these goals, and the organizational
culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other.
Purpose: We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to
identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical
centers that are able to provide inpatient care that is both evidence based and patient centered from those where
performance is either mixed or low in both domains.
Methodology/Approach: We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers
selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational
literature, as well as emergent themes.
Results: We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique
characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment
where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures
with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that
facilitated delivery of both EBP and PCC.
Conclusions and Practice Implications: Organizations that excel in providing both EBP and PCC exhibit unique characteristics and
processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas
that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.
Key words: evidence-based practice, organizational culture, patient-centered care
T
wo major trends in health care over the past 10 years these aims are complementary: Improvements in one will en-
have been the moves to evidence-based medicine (EBM), hance performance in others. It might seem that combining
often referred to as evidence-based practice (EBP), effective EBP and PCC could only enhance patient care.
and patient-centered care (PCC). In Crossing the Quality However, many argue that there is a fundamental tension
Chasm, the Institute of Medicine (IOM) proposed the Six between these goals (Hasnain-Wynia, 2006; Kitson, 2002;
Aims, a set of performance characteristics that together define McLaughlin & Kaluzny, 2000). Even the IOM definitions
how health care can and should be provided (Committee on of effective and patient-centered aims seem to provide poten-
Quality of Health Care in America, 2001b). The Six Aims, tial conflict, as effective care is defined as being “based on sci-
as relevant now as when they were first introduced, set forth entific knowledge to all who could benefit,” whereas PCC is
the expectation that health care delivery should be safe, effec- defined as being “respectful of and responsive to individual
tive, patient centered, timely, efficient, and equitable. Often, patient preferences, needs, and values, and ensuring that
Ryann L. Engle, MPH, is Research Health Scientist, Senior Project Manager, Center Review Board. The contents of this article are those of the authors and do not
for Healthcare Organization and Implementation Research, Department of Veterans represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
Affairs, Boston, Massachusetts. E-mail: . Findings presented in this article were presented as the Best Organizational Behavior
David C. Mohr, PhD, is Investigator, Center for Healthcare Organization and and Management Abstract at the June 2015 AcademyHealth Annual Research Meeting
Implementation Research, Department of Veterans Affairs, and Research Assistant in Minneapolis, MN. The authors would like to thank the larger research team.
Professor, Department of Health Law, Policy & Management, Boston University The authors have disclosed that they have no significant relationship with, or
School of Public Health, Massachusetts. financial interest in, any commercial companies pertaining to this article.
Sally K. Holmes, MBA, is Co-Investigator, Center for Healthcare Organization and
Supplemental digital content is available for this article. Direct URL citations appear in
Implementation Research, Department of Veterans Affairs, Boston, Massachusetts (retired). the printed text and are provided in the HTML and PDF versions of this article on the
Marjorie Nealon Seibert, MBA, is Senior Project Manager, Center for Healthcare Organization
journal’s Web site (www.hcmrjournal.com).
and Implementation Research, Department of Veterans Affairs, Boston, Massachusetts (retired).
Melissa Afable, MPH, is Project Manager, Partners HealthCare, Department of This is an open-access article distributed under the terms of the Creative Commons
Quality, Safety and Value, Department of Veterans Affairs, Boston, Massachusetts. Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
Jenniffer Leyson, MA, is Analyst, Center for Healthcare Organization and permissible to download and share the work provided it is properly cited. The work
Implementation Research, Department of Veterans Affairs, Boston, Massachusetts. cannot be changed in any way or used commercially without permission from the journal.
Mark Meterko, PhD, is Senior Survey Methodologist, VHA Office of Reporting, Written work prepared by employees of the Federal Government as part of their
Analytics, Performance, Improvement and Deployment, Department of Veterans official duties is, under the U.S. Copyright Act, a "work of the United States
Affairs, and Research Associate Professor, Department of Health Law, Policy & Government" for which copyright protection under Title 17 of the United States
Management, Boston University School of Public Health, Massachusetts. Code is not available. As such, copyright does not extend to the contributions of
This study was funded by the U.S. Department of Veterans Affairs Grant IIR 07-244 employees of the Federal Government.
and received institutional review board approval from the VA Central Institutional DOI: 10.1097/HMR.0000000000000254
174 Health Care Manage Rev • July-September 2021 • Volume 46 • Number 3 www.hcmrjournal.com
4/16/2026, 1:43:23 PM
, Evidence-based
Latest practice and patient-centered care Doing both well Ryann L. Engle
patient values guide all clinical decisions” (Committee on Veterans Affairs (VA), what is needed now is “further investiga-
Quality of Health Care in America, 2001b). In addition, the tion regarding why some settings have a more patient-centered
provision of PCC, with its emphasis on being responsive to culture or how they facilitate PCC.”
individual patient and family preferences, needs, and values, This prior research on the organizational characteristics
can potentially conflict with the delivery of effective and associated with effective EBP and PCC in isolation leads to
efficient care via standardized processes of EBP (Bensing, our research objective, which is to expand the knowledge
2000; Hasnain-Wynia, 2006; Kitson, 2002; Sidani, Epstein, and understanding of how health care organizations can de-
& Miranda, 2006). This apparent paradox raises significant liver both evidence-based care and PCC. To do this, we exam-
questions for health care providers, including whether medical ine organizational characteristics that can strengthen and/or
care can simultaneously be guided by evidence while achieving facilitate an emphasis on PCC while also supporting EBP.
patient-centeredness. The current qualitative investigation ex-
amines characteristics of medical centers in relation to how Conceptual Framework
well they are able to achieve these dual goals. We relied on the organizational transformation model (OTM)
to guide our exploration of these issues. The OTM consists
Dual Goals: Conflicting or Synergistic? of five elements related to transformation of care: impetus
If EBP and PCC are each effective methods for improving the to change, leadership commitment to quality, improvement
quality of care, then one would anticipate that doing well on initiatives, alignment between organizational goals and re-
both could lead to multiple benefits. EBP and PCC can also sources, and integration of intraorganizational boundaries
represent opposing tendencies toward standardization on (Lukas et al., 2007). The model is derived from a demonstra-
one hand and customization of medical practice around tion program involving several high-performing hospitals
patient preferences on the other (Hasnain-Wynia, 2006; looking to further “pursue perfection” by providing appro-
Kitson, 2002). Providers may see a focus on guideline adher- priate, cost-effective, and safe care and services that met pa-
ence around EBP as limiting professional autonomy and/or tients’ unique needs and preferences (Robert Wood Johnson
feel that the surveys frequently used to assess PCC do not Foundation, 2010). The OTM identifies those characteristics
adequately reflect the quality of care they provide. Further that explain how organizations move from short-term im-
adding to this tension is the growing use of public reporting provement projects to sustainable changes. Although the model
data, through formal sources involving standardized mea- was framed around practices leading to successful changes in or-
sures such as Hospital Compare and Physician Compare ganizations, it also has value as a framework to understanding
(Centers for Medicare & Medicaid Services, 2018), as well as the challenges and tensions associated with efforts to achieve
consumer-oriented websites. In contrast to the patient-level both EBP and PCC. The model has been applied in studies ex-
studies previously described, efforts to relate quality and patient amining hospital programs to reduce readmissions (Mitchell
ratings at an organization level have generally shown only et al., 2016), hospital pressure ulcer prevention (Soban, Kim,
weak or no meaningful associations (Emmert, Meszmer, & Yuan, & Miltner, 2017), and supportive housing for the home-
Schlesinger, 2018; Hu et al., 2017). A potential reason for less (Kertesz et al., 2014). The OTM provides our framework for
the latter finding may be the conflicts raised in trying to de- identifying the hospital characteristics and practices that are es-
liver both EBP and PCC. sential to meet both EBM and PCC goals.
Other perspectives, however, suggest that EBM and PCC
may not be so diametrically opposed. In advocating for EBM Methods
to meet the aim of delivering effective patient care, the IOM In this article, we focus on the results of the qualitative analysis
uses an updated definition of EBM adapted from Sackett, from a larger mixed-methods study whereby we sought to iden-
Rosenberg, Haynes, Haynes, & Richardson (2007) that incor- tify characteristics that distinguish organizations that are able to
porates elements of PCC to include patient preferences into deliver care that is both evidence based and patient centered.
clinical decisions (Committee on Quality of Health Care in
America, 2001a). The potential synergy between standardiza- Setting
tion and customer responsiveness is bolstered by research For more than 20 years, VA has assessed patients’ percep-
findings that standardization and guidelines enhanced the ex- tions of their health care experience by using, at the time
perience of customers, for example, by promoting efficiency of this study’s initiation, a measure based on the Picker Insti-
in the conduct of routine tasks and leaving more time to at- tute self-report inpatient survey, one of the flagship instru-
tend to individuals’ needs. Standardized work processes ments of the early PCC movement (Cleary et al., 1991).
positively moderated the relationship between a creative VA has been conducting mailed satisfaction surveys since
work climate and customer satisfaction (Gilson, Mathieu, 1995 to assess inpatient care experiences as priority compo-
Shalley, & Ruddy, 2005). There is a growing literature sug- nents of high-quality medical care. All medical centers partic-
gesting that an organizational model in which EBM and ipate in the survey since its start. Bed sections contacted
PCC could dovetail would be one in which EBM provided include medicine, surgery, neurology, rehabilitation, spinal
specific tools for delivery of high-quality care, and patients cord injury, and psychiatry. For our purposes, we used only
were involved in making decisions about the application of scores from patients discharged from medicine bed sec-
those tools. As observed by Flach et al. (2004) in concluding tions from October 2008 to March 2009. In addition,
their study of PCC and the delivery of preventive services in VA has been in the forefront of the movement toward
EBP–PCC www.hcmrjournal.com 175
4/16/2026, 1:43:23 PM
Latest practice and patient-centered care Doing both well Ryann L. Engle
Feature
Evidence-based practice and patient-centered care:
Doing both well
Ryann L. Engle • David C. Mohr • Sally K. Holmes • Marjorie Nealon Seibert • Melissa Afable • Jenniffer Leyson • Mark Meterko
Background: Health care organizations increasingly strive to deliver care that is both evidence based and patient centered.
Although often complementary, fundamental contradictions may exist between these goals, and the organizational
culture and infrastructure necessary to be successful in one domain may inherently diminish performance in the other.
Purpose: We assessed the relationship between evidence-based practice (EBP) and patient-centered care (PCC) by seeking to
identify specific behavioral and process mechanisms, along with organizational characteristics that distinguish medical
centers that are able to provide inpatient care that is both evidence based and patient centered from those where
performance is either mixed or low in both domains.
Methodology/Approach: We analyzed interview data from 142 employees at 12 Veterans Affairs Medical Centers
selected based on EBP and PCC performance (high, low, or mixed) using a priori constructs consistent with organizational
literature, as well as emergent themes.
Results: We confirmed that tensions may arise when attempting to deliver both EBP and PCC and found unique
characteristics of organizations that do both well. High-performing sites exhibited organizational cultures of empowerment
where both EBP and PCC expectations were emphasized; provided formal and informal institutional supports and structures
with regard to PCC and EBP; and fostered multidisciplinary, multidirectional approaches to care and communication that
facilitated delivery of both EBP and PCC.
Conclusions and Practice Implications: Organizations that excel in providing both EBP and PCC exhibit unique characteristics and
processes. Recognizing that some characteristics such as culture are difficult to change, these findings nonetheless highlight areas
that could be enhanced by medical centers striving to deliver care that is both evidence based and patient centered.
Key words: evidence-based practice, organizational culture, patient-centered care
T
wo major trends in health care over the past 10 years these aims are complementary: Improvements in one will en-
have been the moves to evidence-based medicine (EBM), hance performance in others. It might seem that combining
often referred to as evidence-based practice (EBP), effective EBP and PCC could only enhance patient care.
and patient-centered care (PCC). In Crossing the Quality However, many argue that there is a fundamental tension
Chasm, the Institute of Medicine (IOM) proposed the Six between these goals (Hasnain-Wynia, 2006; Kitson, 2002;
Aims, a set of performance characteristics that together define McLaughlin & Kaluzny, 2000). Even the IOM definitions
how health care can and should be provided (Committee on of effective and patient-centered aims seem to provide poten-
Quality of Health Care in America, 2001b). The Six Aims, tial conflict, as effective care is defined as being “based on sci-
as relevant now as when they were first introduced, set forth entific knowledge to all who could benefit,” whereas PCC is
the expectation that health care delivery should be safe, effec- defined as being “respectful of and responsive to individual
tive, patient centered, timely, efficient, and equitable. Often, patient preferences, needs, and values, and ensuring that
Ryann L. Engle, MPH, is Research Health Scientist, Senior Project Manager, Center Review Board. The contents of this article are those of the authors and do not
for Healthcare Organization and Implementation Research, Department of Veterans represent the views of the U.S. Department of Veterans Affairs or the U.S. Government.
Affairs, Boston, Massachusetts. E-mail: . Findings presented in this article were presented as the Best Organizational Behavior
David C. Mohr, PhD, is Investigator, Center for Healthcare Organization and and Management Abstract at the June 2015 AcademyHealth Annual Research Meeting
Implementation Research, Department of Veterans Affairs, and Research Assistant in Minneapolis, MN. The authors would like to thank the larger research team.
Professor, Department of Health Law, Policy & Management, Boston University The authors have disclosed that they have no significant relationship with, or
School of Public Health, Massachusetts. financial interest in, any commercial companies pertaining to this article.
Sally K. Holmes, MBA, is Co-Investigator, Center for Healthcare Organization and
Supplemental digital content is available for this article. Direct URL citations appear in
Implementation Research, Department of Veterans Affairs, Boston, Massachusetts (retired). the printed text and are provided in the HTML and PDF versions of this article on the
Marjorie Nealon Seibert, MBA, is Senior Project Manager, Center for Healthcare Organization
journal’s Web site (www.hcmrjournal.com).
and Implementation Research, Department of Veterans Affairs, Boston, Massachusetts (retired).
Melissa Afable, MPH, is Project Manager, Partners HealthCare, Department of This is an open-access article distributed under the terms of the Creative Commons
Quality, Safety and Value, Department of Veterans Affairs, Boston, Massachusetts. Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
Jenniffer Leyson, MA, is Analyst, Center for Healthcare Organization and permissible to download and share the work provided it is properly cited. The work
Implementation Research, Department of Veterans Affairs, Boston, Massachusetts. cannot be changed in any way or used commercially without permission from the journal.
Mark Meterko, PhD, is Senior Survey Methodologist, VHA Office of Reporting, Written work prepared by employees of the Federal Government as part of their
Analytics, Performance, Improvement and Deployment, Department of Veterans official duties is, under the U.S. Copyright Act, a "work of the United States
Affairs, and Research Associate Professor, Department of Health Law, Policy & Government" for which copyright protection under Title 17 of the United States
Management, Boston University School of Public Health, Massachusetts. Code is not available. As such, copyright does not extend to the contributions of
This study was funded by the U.S. Department of Veterans Affairs Grant IIR 07-244 employees of the Federal Government.
and received institutional review board approval from the VA Central Institutional DOI: 10.1097/HMR.0000000000000254
174 Health Care Manage Rev • July-September 2021 • Volume 46 • Number 3 www.hcmrjournal.com
4/16/2026, 1:43:23 PM
, Evidence-based
Latest practice and patient-centered care Doing both well Ryann L. Engle
patient values guide all clinical decisions” (Committee on Veterans Affairs (VA), what is needed now is “further investiga-
Quality of Health Care in America, 2001b). In addition, the tion regarding why some settings have a more patient-centered
provision of PCC, with its emphasis on being responsive to culture or how they facilitate PCC.”
individual patient and family preferences, needs, and values, This prior research on the organizational characteristics
can potentially conflict with the delivery of effective and associated with effective EBP and PCC in isolation leads to
efficient care via standardized processes of EBP (Bensing, our research objective, which is to expand the knowledge
2000; Hasnain-Wynia, 2006; Kitson, 2002; Sidani, Epstein, and understanding of how health care organizations can de-
& Miranda, 2006). This apparent paradox raises significant liver both evidence-based care and PCC. To do this, we exam-
questions for health care providers, including whether medical ine organizational characteristics that can strengthen and/or
care can simultaneously be guided by evidence while achieving facilitate an emphasis on PCC while also supporting EBP.
patient-centeredness. The current qualitative investigation ex-
amines characteristics of medical centers in relation to how Conceptual Framework
well they are able to achieve these dual goals. We relied on the organizational transformation model (OTM)
to guide our exploration of these issues. The OTM consists
Dual Goals: Conflicting or Synergistic? of five elements related to transformation of care: impetus
If EBP and PCC are each effective methods for improving the to change, leadership commitment to quality, improvement
quality of care, then one would anticipate that doing well on initiatives, alignment between organizational goals and re-
both could lead to multiple benefits. EBP and PCC can also sources, and integration of intraorganizational boundaries
represent opposing tendencies toward standardization on (Lukas et al., 2007). The model is derived from a demonstra-
one hand and customization of medical practice around tion program involving several high-performing hospitals
patient preferences on the other (Hasnain-Wynia, 2006; looking to further “pursue perfection” by providing appro-
Kitson, 2002). Providers may see a focus on guideline adher- priate, cost-effective, and safe care and services that met pa-
ence around EBP as limiting professional autonomy and/or tients’ unique needs and preferences (Robert Wood Johnson
feel that the surveys frequently used to assess PCC do not Foundation, 2010). The OTM identifies those characteristics
adequately reflect the quality of care they provide. Further that explain how organizations move from short-term im-
adding to this tension is the growing use of public reporting provement projects to sustainable changes. Although the model
data, through formal sources involving standardized mea- was framed around practices leading to successful changes in or-
sures such as Hospital Compare and Physician Compare ganizations, it also has value as a framework to understanding
(Centers for Medicare & Medicaid Services, 2018), as well as the challenges and tensions associated with efforts to achieve
consumer-oriented websites. In contrast to the patient-level both EBP and PCC. The model has been applied in studies ex-
studies previously described, efforts to relate quality and patient amining hospital programs to reduce readmissions (Mitchell
ratings at an organization level have generally shown only et al., 2016), hospital pressure ulcer prevention (Soban, Kim,
weak or no meaningful associations (Emmert, Meszmer, & Yuan, & Miltner, 2017), and supportive housing for the home-
Schlesinger, 2018; Hu et al., 2017). A potential reason for less (Kertesz et al., 2014). The OTM provides our framework for
the latter finding may be the conflicts raised in trying to de- identifying the hospital characteristics and practices that are es-
liver both EBP and PCC. sential to meet both EBM and PCC goals.
Other perspectives, however, suggest that EBM and PCC
may not be so diametrically opposed. In advocating for EBM Methods
to meet the aim of delivering effective patient care, the IOM In this article, we focus on the results of the qualitative analysis
uses an updated definition of EBM adapted from Sackett, from a larger mixed-methods study whereby we sought to iden-
Rosenberg, Haynes, Haynes, & Richardson (2007) that incor- tify characteristics that distinguish organizations that are able to
porates elements of PCC to include patient preferences into deliver care that is both evidence based and patient centered.
clinical decisions (Committee on Quality of Health Care in
America, 2001a). The potential synergy between standardiza- Setting
tion and customer responsiveness is bolstered by research For more than 20 years, VA has assessed patients’ percep-
findings that standardization and guidelines enhanced the ex- tions of their health care experience by using, at the time
perience of customers, for example, by promoting efficiency of this study’s initiation, a measure based on the Picker Insti-
in the conduct of routine tasks and leaving more time to at- tute self-report inpatient survey, one of the flagship instru-
tend to individuals’ needs. Standardized work processes ments of the early PCC movement (Cleary et al., 1991).
positively moderated the relationship between a creative VA has been conducting mailed satisfaction surveys since
work climate and customer satisfaction (Gilson, Mathieu, 1995 to assess inpatient care experiences as priority compo-
Shalley, & Ruddy, 2005). There is a growing literature sug- nents of high-quality medical care. All medical centers partic-
gesting that an organizational model in which EBM and ipate in the survey since its start. Bed sections contacted
PCC could dovetail would be one in which EBM provided include medicine, surgery, neurology, rehabilitation, spinal
specific tools for delivery of high-quality care, and patients cord injury, and psychiatry. For our purposes, we used only
were involved in making decisions about the application of scores from patients discharged from medicine bed sec-
those tools. As observed by Flach et al. (2004) in concluding tions from October 2008 to March 2009. In addition,
their study of PCC and the delivery of preventive services in VA has been in the forefront of the movement toward
EBP–PCC www.hcmrjournal.com 175
4/16/2026, 1:43:23 PM
