We are honored that three such distinguished colleagues commented on our paper. Before responding, we want to reiterate what we wrote in our article-the assumption that managers should apply as much pertinent information as possible (including experience from other organizations or fields) to their decision making is sound and noncontroversial. Our purpose was limited to drawing attention to additional assumptions that underlie the present advocacy for evidence-based management but are not made explicit: decisions will yield anticipated results; they are generalizable across organizations; and evidence is objective and context free. We focused on these assumptions because health care organizations are complex systems, they are not mechanistic structures, and because we see potential pitfalls if evidence-based management is pursued with these unexpressed assumptions taken for granted.

All three commentators agreed with us that health care organizations are complex systems and all three mentioned explicitly or implicitly that managers do or should discard practices that they deem ineffective. That is consistent with our own thinking and provides a sound basis for a continuing dialogue about evidence-based management. We were puzzled, therefore, when Banaszak-Holl wrote later that "the trend is actually away from adaptive systems and toward the use of standardized and replicable processes" and brushed aside our concerns as "poorly grounded."

Both Begun and McDaniel agreed with our concern about the broad scope of evidence-based management as presented by its advocates, and both suggested limiting it to narrower circumstances or purposes. The former, for example, supports Shortell, Rundall, and Hsu (2007) who advocate for evidence-based management to support the implementation of specific evidence-based clinical guidelines. As Begun wrote, "[These] are arenas of management life where scientific evidence is convincing enough that it should affect decision making." McDaniel similarly limited the scope of evidence-based management to "local" areas and enriched the discussion further when he viewed evidence not as a ready solution but as an "opportunity for relevant dialogue." This view encourages managers to seek evidence but does not compel them to merely replicate it; rather, they are advised to use it as a focus for reflection in their particular context and as a foundation for learning. McDaniel also suggested small-scale experiments or pilot projects to clarify the appropriateness of a management practice in a specific context. We find all the above approaches compelling and support them wholeheartedly.

We expressed concern that unless there is more transparency about the unspoken assumptions underlying the advocacy for evidence-based management, the calls for management practice guidelines will increase. McDaniel and Begun raised additional concerns. The former saw danger in managers fostering too much consensus because "tension and conflict can be sources of creativity," whereas the latter simply stated that it is a "managers' jobs to use [the evidence] or not." This contrasts sharply with Banaszak-Holl who argued that different health care organizations already have "similar missions, stakeholders, and regulatory requirements" and that the evidence-based management movement will require them to reach "consensus about managerial practice." That is a tall order, indeed. Of even greater concern is that she then asserted that managers who fail to investigate prior experience are "guilty of gross violation of standards of prudence and trust." Such an argument sets up a straw man in the form of managers who deliberately make decisions in a vacuum (and as we said in our paper, that is not an assumption we should make). We are concerned about a culture in which managers have to defend themselves against accusations of gross violation of standards of prudence and trust if they make particularistic decisions for their specific context and that somehow becomes interpreted as not having sought evidence.

We noted with interest Banaszak-Holl's reference to institutional theory and the associated "conformity in the adoption of management practices." This is a subject near and dear to our hearts, as our colleagues know (for example, see, Arndt & Bigelow, 2000; Bigelow & Arndt, 2000). Although the commentator assumed that institutional pressures are a tool for the diffusion of best practices, theory and experience suggest that there will be widespread symbolic compliance as well. Health care organizations have for decades been pressured to adopt specific management practices; each was offered as a transformational solution to problems in the functioning of our health care organizations, and each was superseded after a few years by another one. Did we really expect managers each time to spend untold resources on a full-scale adoption, only to start from scratch a few years later when they were informed that the approach had been flawed after all and needed to be replaced by another large scale intervention? This is a question Begun raised in his commentary when he wondered about the relevance of management research to practitioners.

In conclusion, we agree with McDaniel and Begun that managers should include evidence from other fields or organizations when making decisions. We also agree that managers and individual organizations need to be the judge whether a practice is applicable to their circumstances and settings. We disagree with McDaniel, however, that it is contradictory to study the effectiveness of evidence-based management. Proponents of evidence-based management have raised themselves above the evidentiary standards to which they hold health care organizations and their claims are not empirically grounded. As with any tool that managers use in decision making, there is value in studying outcomes across organizations and decisions. A tool that can aid decision making when applied, as Begun puts it, to "(relatively) simple systems in (relatively) stable environments" and when used to guide local action deserves study. If the concept becomes overextended, we risk losing what value it has to offer.

We agree with Banaszak-Holl that critical issues should be raised about evidence-based management while it is in its early stages, but we cannot agree with her that health care organizations are not complex systems or that generic best practices can be developed that can be inserted into health care organizations regardless of context. We further believe that the overly broad normative prescriptions for evidence-based management will force health care organizations to focus as much (if not more) on signaling compliance as on genuine adoption, as has been the case with other management practices.

We raised one other concern in our paper about the nature of evidence. None of the commentaries address this specifically, so we want to refer back to it briefly as a topic that requires attention. First, what counts as "evidence" and, second, what counts as "best practice." Both are open to interpretation. The former is subject to managers' or researchers' needs and judgments, whereas the latter may be assessed quite differently by parties ranging from patients to health care organizations, third party payers, local communities, regulators, and others.

We are grateful to the editor that she made this forum possible and hope that we will all have opportunity to continue this dialogue among ourselves and with other colleagues before the concept of evidence-based management becomes overextended or saturated with taken for granted assumptions.

Margarete Arndt, DBA

Barbara Bigelow, PhD

References