Background Evidence-based practice has permeated professional life as a normative ideal. The resulting movement of ‘evidence-based management’ is premised on assumed positive consequences of managers making organisational decisions informed by research, rather than by personal experience alone. However, we know little about how health-care managers engage with information and knowledge in practice, especially at the highest level. Objectives The study aimed to investigate how chief executive officers (CEOs) of NHS trusts make decisions and mobilise particular knowledge and ‘evidence’ in the course of their day-to-day activities. Design The study was conducted between March 2011 and May 2013. We employed a qualitative naturalistic approach, combining in-depth observation with interviews and documentary analysis. Seven CEOs of acute and mental health NHS trusts in England were shadowed for an average of 5 weeks each. This sample included four women and three men. To protect the anonymity of our informants, and following customary academic practice in the social sciences, in this report we refer to all our participants using the female pronoun. We aimed to maximise sample diversity regarding professional background, career stage and organisational characteristics. Analysis was a reiterative process, led by two empirical researchers, who continuously examined emergent data and undertook cross-case comparative analysis. This was informed by team meetings, discussions with an expert advisory panel, and feedback from research participants and other senior NHS managers. Results CEOs seek information and use knowledge all the time, for three main purposes: making decisions; accounting for decisions already made; and making sense. The last of these is by far the most common, with significant effort aimed at ‘connecting the dots’ and constructing (‘weaving’) a sense of the present and future for their own and others’ consumption. This is most often accomplished conversationally, including via an inner conversational circle of trusted colleagues. CEOs very rarely mobilise knowledge in the canonical way described in many of the existing models – though this does not make them poorly informed or irrational decision-makers. In particular, they rarely search, retrieve, consult and quote scientific and other forms of formalised evidence in person. Instead, they systematically ask others to do so and put in place the necessary mechanisms that allow them to progress from intuition to facts. Their knowledge and information work is therefore not so much about decision-making as about knowledgeability – understood as a personal and organisational capability: knowledge-ability. How CEOs’ knowledgeability is accomplished, why and in relation to what objects differs on the basis of a number of contextual factors, including the specific issue at hand, their personal style and the nature of everyday work. We define such an arrangement as the (personal) knowledgeability infrastructure of CEOs. Conclusions By challenging prevailing models of evidence-based practice, our findings could inform the initiatives supporting the work of NHS CEOs and help them become more effective. There are a number of skills that new CEOs may need to learn, and a number of skills, behaviours and attitudes that may need to change over time according to changing circumstances, for a CEO, to conduct her job successfully. Our findings suggest a framework for critically examining how, and how effectively, NHS managers may make themselves knowledgeable given the demands of their jobs. Funding details The National Institute for Health Research Health Services and Delivery Research programme.
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May 27, 2015
Alistair Kleebauer 
Open Access