Although the main aim of evidence-based practice (EBP) is improvement of quality of care, and despite all the efforts to build good evidence, the actual use of EBP in every day practice remains low.1 Moreover, the Belgian EBP development, dissemination and implementation landscape remains scattered.2 That is why the Belgian Minister of Public Health decided in 2016 to optimize this situation, by means of a national governance plan for EBP in Belgium.3 This governance plan has to serve a two-fold purpose: first, to steer the programmatic further introduction, dissemination and implementation of EBP, and second, to be adaptive to developments in the health care landscape which should allow for further prioritization and differentiation (e.g. over disciplines or specialties). The focus of the governance plan is at those organizations that develop, validate, disseminate or implement EBP guidelines and other EBP-related products, such as layman guidelines. The governance plan has to secure general conditions and specific requirements: first, quality and accessibility (via trusted media) of EBP products has to be guaranteed; second, EBP literacy in patients and informal care givers has to be improved and facilitated; third, efficiency and coherence of EBP product development, validation, dissemination and implementation have to be guaranteed and fourth, cost of guideline production validation, dissemination and implementation needs to be controlled by the governance structure. In 2016–2017, the EBP plan was created, building on the current practice in the Belgian EBP-domain. The underlying idea was that EBP consists of a number of consecutive steps (life cycle cells): topic prioritization, product development, product validation, active dissemination, implementation in end users and evaluation (Fig. 1). Every life-cycle cell has its coordinator (core partner). The governance plan also makes clear distinction between the purely scientific EBP processes and the governance and management processes of the EBP plan. The former are (and remain) under the responsibility of the EBP experts, whereas the latter will be coordinated and facilitated by an independent third party [network administrative organization (NAO)]. The model also has to ensure that transfer from one life-cycle cell to another is as smooth as possible.
To describe the core elements and the operationalization of the governance model for EBP in Belgium.
The EBP operationalization process builds on the Belgian Knowledge Centre EBP Plan report.3 The operationalization process of the EBP Plan4 is guided by intensive stakeholder involvement (expert opinions, end-user consultation, consensus building), focusing on applicability, feasibility and acceptability of the proposed model. For this purpose, a large number of consecutive workshops were organized, followed by surveys and consultations to assess the degree of acceptance for every part of the model in the different stakeholder groups.
The operationalization process aims to develop a network organization, wherein every potential EBP stakeholder (e.g. developer, disseminator, end-user, patient) can find its place. A critical success factor in this process is building trust. A very important aspect of network organizations, which are an organizational answer to complex challenges, is the absence of hierarchical control. The strength of network organizations lies in the complementarity of the independent partners, to attain goals that single organizations can’t achieve.5 The way network organizations are created can be either organised, based on a free choice of the partners, or mandated. In mandated networks, an external entity orders the partners to collaborate. Mandated networks might however have challenges in building trust. Based on Provan and Kenis6 there are three ways of organizing network governance: shared governance (all the network partners participate in the governance processes, implying extensive formal and informal communication), lead organization (one of the partner organizations sets the strategic guidelines) and the NAO (a separate independent organization takes on the task of network governance). Depending on the number of partners in the network, the level of trust between them, and goal consensus between partners, one of the models is more appropriate. Based on the characteristics of the Belgian landscape, the NAO governance approach was chosen to be the definite model.
The final Belgian EBP NAO-model is in fact a bipolar model (Fig. 2). On the one side the Federal Steering Group, consisting of the funding policy bodies, the Ministerial Cabinet and two advisory knowledge partners, handles political issues and balances interests in the diverse field of institutions at a federal level. On the other hand an extensive monitoring and consultation mechanism (i.e. the Advisory Board and the Core Partner Meeting) is set up to collect, process and act on feedback from every kind of stakeholder. In between these two governance forces, an independent complementary organization is created, that can focus on programmatic aims and operational actors, be it guideline developers, validators, disseminators and implementers, or healthcare workers and patients or their relatives. The decisional power of the NAO is mandated and their financial position is granted by the federal Steering Group. The NAO consists of a manager with strong competencies in network management and a compact executive cell. The main aim of the NAO is to steer, facilitate and support the processes in the EBP Network. The NAO takes into account all the feedback that is collected through multiple channels, processes this information, and advocates the stakeholders’ preferences and needs.
As an in-between, communication, informing, negotiation and support are core activities of the NAO towards the two ‘forces’ in the model. As a consequence, the NAO must be a trusted party to take up this role. Giving the fact that organizational change can lead to resistance, building trust and becoming aware of the sensitivities and goals of every partner are important working points during the start-up phase. At present, consultation of and negotiation with stakeholders is in an advanced phase and the Belgian EBP Network hopes to be operational in the beginning of 2019.
Conflict of interest
The authors report no conflicts of interest.
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