Political visions, practice standards, knowledge and skills, and critical appraisal tools are necessary but not sufficient to ensure effective and efficient EIDM. The characteristics and capacity of public health organizations are also key [1
]. As discussed below, the facilitators and barriers of organizational change identified in this research are similar to themes highlighted by others who have studied the "active ingredients" [49
] of system transformations to promote EIDM and/or quality improvement in public health and other health-related sectors.
System forces, such as national practice standards may compel EIDM-related reforms, but leaders of health care organizations are the "endogenous catalysts" [50
] that stimulate and propel on-the-ground change [1
]. Research has identified attributes and behaviours of effective leaders of organizational transformation for EIDM, including setting, steering and staying the course for change, becoming active participants in change efforts [53
], the readiness and ability to secure and (re)allocate human, material and fiscal resources, and nurturing a culture that is open to change and values the inclusion of research evidence in decision making [49
]. One aspect of leadership the literature does not emphasize that was identified in this study is stability. Long-term involvement of a consistent group of senior leaders has reinforced the presence, prominence and permanence of PPH's EIDM initiative.
Consistent with other research on organizational change and capacity building for EIDM [50
], the findings of this study demonstrate the value of enhancing formal and informal relational structures. Clubs, committees and other groups provide opportunities for staff to get involved, exchange ideas, gain experience, assume responsibility, and take ownership. Structures that bring staff together are important, but some authors argue the pressing priority for advancing EIDM is building organizational structures that facilitate access to knowledge [1
]. Strategic goals, critical appraisal skills and enthusiasm for EIDM are of limited use if organizations lack the infrastructure to acquire research evidence. It is not enough for public health professionals to rely on academic or personal connections to help find and obtain research for decision making. These organizations need direct and easy access to technology for EIDM, to information specialists and to full-text research literature. Recognizing the critical importance of this aspect of capacity building for EIDM, PPH has invested significant time, effort and funds to develop its internal library infrastructure and expertise. Understanding that similar efforts and investments may be difficult for smaller, remote and/or less well funded health departments, there is a need for organizations (both those endowed and those in need) as well as the provincial and national public health systems, to explore opportunities for staff and IT resource sharing, using virtual networks, creating consortiums to procure group rights to access databases and journals of restricted circulation, and encouraging publication of relevant research in open access sources.
There is agreement in the literature and with the findings of this study that, in general, the public health workforce lacks research methods and critical appraisal skills, and that more formal and advanced training is needed on the concepts, tools, technologies and applications of EIDM [49
]. At the outset of PPH's initiative, very few staff had the requisite skills to conduct efficient and effective reviews of the literature but by 2010 a large number of staff had participated in EIDM training workshops and plans were underway for an organization-wide training platform. By designating a significant portion of a senior leader's time to advance the EIDM priority and creating several new positions dedicated to EIDM-related work, PPH also counteracted concerns about negative impacts on performance when efforts are under-staffed or rely on volunteers [1
]. Including EIDM-related expectations and opportunities within an organization's performance, accountability and incentive structures is another facilitative factor identified in the literature [49
] and in the findings of this study. What the literature does not address but was critical to advance training and increase the number of EIDM-related staff positions in this case, was the organization's decision to commit significant long-term core funding for these activities and salaries.
A supportive culture has been identified as a key contextual determinant of change to promote EIDM in health-related settings [55
]. The results of this study mirror what other authors [49
] suggest are key characteristics of such cultures, for example: valuing people, learning, and the use of research evidence; encouraging innovation, out-of-the-box thinking and risk-taking; and making time for critical reflection a priority. Compared to selecting tools, training staff and other more technical and/or discrete aspects of EIDM capacity building, changing the culture of an organization is a much harder and longer process [58
]. As demonstrated in this study, there is value in beginning with a long-term Strategic Plan that explicitly anticipates and allows sufficient time for EIDM to become part of the everyday and expected routines of the organization and its workforce.
There is increasing recognition of the critical importance of knowledge management for effective EIDM [1
]. As learned in this study, EIDM approaches require, use and produce significant volumes of information. However, the structures, technology and expertise within organizations either do not exist or are not are not well matched to manage this knowledge. Capacity building efforts at PPH included plans to create an in-house knowledge management system. While there is certainly value in an organization taking steps to manage its internal knowledge, there would be greater value in a comprehensive knowledge management system that serves the public health sector as a whole. The application of knowledge may be different across settings, but the issues facing health units and the sources of research on these problems would likely be the same or very similar. Making available the work already done by one organization to synthesize, appraise and use evidence for decision making to others would contribute to maximizing efficiencies, reducing duplication, and increasing transparency and consistency. To this end, some internet-based platforms have been developed to help improve access to, and retrieval and use of scientific evidence and other forms of knowledge for decision making in public health [e.g., 60]. In addition, public health leaders in Canada have begun thinking and talking about developing a national strategy for knowledge management [61
]; operationalizing this vision, though challenging, would provide much needed system level capacity for EIDM.
A number of authors address the importance of and mechanisms for communication in organizational change and capacity building for EIDM. They emphasize the need for senior leaders to communicate early and continuously about the rationale, plans, activities, progress and practical implications of change [54
]. They also discuss designating and using multiple channels to increase awareness, promote dialogue, and generate widespread buy-in and adoption [1
]. Furthermore, research has demonstrated the value of developing a comprehensive communication strategy that includes dedicated resources [50
]. While the nature of communication regarding the EIDM initiative reflected some of the qualities described in the literature, this is an area where more concerted and systematic efforts are needed at PPH. Informants in this study recognized the lack of and need for an organization-wide, comprehensive, EIDM-specific communication plan and senior leaders indicated that developing and resourcing this strategy would be a key priority of future efforts.
] states "we are beginning to realize that the change itself is not usually the problem. The problem is our reaction to change" (p. 239). Like Crow, many authors [52
] identify the need for management strategies that help leaders acknowledge and address staff emotions related to change, new expectations and altered responsibilities. Efforts to build capacity for EIDM must focus on the tasks and resources required to conduct evidence reviews, but to be successful, they must also identify and respond to the needs of the people who perform this work [57
]. The findings of this study reinforce the utility of change management frameworks and highlight the importance of recognizing and addressing the range of negative and positive emotional reactions to EIDM and to organizational change.
It is clear there are many catalysts and components of organizational change to promote EIDM. Implementing a comprehensive EIDM strategy is similar to the implementation of large scale enterprise technologies such as customer relationship management (CRM) or performance measurement systems. It requires contextual preparation, incremental efforts, adaptive capacity, on-going resource investments, attention to human needs, and an awareness of the interdependence of intervention elements and stakeholder groups. This case study demonstrates the complexity and expansiveness of the activities, factors and dynamics involved in making EIDM a standard feature of public health practice. It also reinforces the notion that EIDM cannot be pursued or achieved by an organization in isolation. Partnerships with other health settings, access to external knowledge sources, and inputs from provincial and national public health agencies are necessary to realize EIDM's potential to have consequential and sustainable impacts on public health services and health outcomes.
There are several limitations of this research. First, as a single-site case study no assumptions can be made regarding the generalizability of the findings. Public health and other health care organizations interested in applying the knowledge will need to consider contextual similarities and differences to assess the theoretical transferability of the findings to their unique settings [41
]. Second, the scope of the study focused only on the first two years of a 10-year strategic initiative. Thus, while the findings capture a critical period of organizational change and implementation, they cannot anticipate the future progression, facilitators and/or barriers of efforts to build EIDM capacity. The timeframe of the study also precluded any evaluation of actual performance or outcomes related to EIDM. Finally, the decision was made to only include staff responsible for literature reviews and individuals most involved in the initial roll out of the EIDM initiative. Therefore, this study does not consider the perspectives of the front-line professionals who will eventually be involved in and impacted by the organization-level change.
Further research is needed to expand our understanding of, and provide practical guidance for organizational capacity building for EIDM. It will be important to continue studying the characteristics and effectiveness of strategies used to increase and improve uptake of research evidence in health care decision making. Individual organizations planning or undergoing changes to promote EIDM would benefit from developmental and formative evaluations [28
] that can offer practical, critical and real-time insights and assessments to inform and/or re-calibrate efforts. Studies that include after action reviews [64
] and summative evaluations [31
] are needed to demonstrate if and how EIDM approaches and organizational changes are actually impacting public health policy and practice. Longitudinal research will be important to assess the sustainability of organizational changes and strategies to promote EIDM. It would be useful if research could identify the appropriate combination, sequence, duration, intensity and audiences for the range of EIDM-related activities. To contribute to a more general theory of organizational capacity building for EIDM, multi-site case studies are needed that compare and contrast the dynamics, resources, mechanisms and impacts of EIDM initiatives in different organizational contexts. Finally, public health is not the only sector pursuing efforts to build organizational capacity for EIDM [e.g., 55,65-67] and there is much that could be learned and achieved through cross-disciplinary collaborations.