Background
Complexity science in health care
Methods
Study design
Study setting
Data collection
Data analysis based on the combined Cynefin and adaptive leadership frameworks
Situation | Problem definition | Response | Primary locus of responsibility for the work | Kind of work | Decision-making process |
---|---|---|---|---|---|
Simple | Clear Ordered universe with clear causality | Clear Answers are self-evident, undisputed, and can be determined based on facts and evidence | Manager | Technical Often a question of solution implementation | Sense Categorize Respond Responses are developed through the categorization of existing facts |
Complicated | Clear Ordered universe with clear causality, though not perceived by everyone | Requires learning May contain multiple correct answers; involves analysis, expert consultations, and the creation of working groups. Requires coordination and collaboration, time consuming, often with a tradeoff between the “best” answer and making a decision, but complete data becomes available … eventually | Manager and staff | Technical and adaptive Often a question of solution implementation and evolution of new responses through experimentation and discovery | Sense Analyze Respond Responses are developed based on analyzing several options |
Complex | Requires learning Unordered universe without clear causality | Requires learning No right answers exist – decisions often based on incomplete data | Staff > manager | Adaptive Often a question of evolution of new responses through experimentation and discovery | Probe Sense Respond Responses are developed by letting them emerge by testing different ideas |
Chaotic | Requires action to create stability in an unordered universe | Requires action to stabilize in order to gain perspective and enable diagnosis – no point to search for right answers | Manager | Technical | Act Sense Respond By first acting, order can be established so that a response can be developed |
Results
Case description
I do not think we had developed it [the change strategy and process] if we had not gotten this task. It may well be that we had developed some small things, but this whole big “set-up” is initiated, it is driven by the requirements we must meet. (Department manager 1)
Completely perplexed, I spent a weekend in almost total despair, because I could not figure out anything. What would be wise? Which way should we go? I went for a long walk on Sunday, and suddenly I thought, “OK, this is what we need to do: we need to work intensively with it [the efficiency requirement], and with the patient pathways, and we have to take a professional path!” It's the only thing that works; all that managerial "You have to understand, we have to..." is not something the employees have any use for. (Department manager 2)
The purpose of setting up a number of working groups that work with patient pathways and the organization is to stay focused on the professional task, which we must solve in our department with the same high quality in the new hospital, but adapted to the new [smaller] physical space and with reduced staff availability (Master plan, September 2013).
Multiple changes implemented
Case analysis
Complexity framework analysis
Situation (n = 53) | Problem definitiona | Responsea | Primary locus of responsibility for the work | Kind of work | Decision-making processa |
---|---|---|---|---|---|
Simple 18 (34%) | Clear 38 (72%) Unnecessary visits by pregnant patients with suspected intrahepatic cholestasis because patients were seen more acutely than evidence suggests is warranted. | Clear 6 (11%) To use recently developed regional guidelines to reduce unnecessary admissions due to trauma in pregnancy. | Manager 3 (6%) Managers were responsible for introducing the new guideline on “trauma in pregnancy” in the electronic guideline collection. | Technical 3 (6%) To implement the new guideline on “Trauma in pregnancy”. | Sense Categorize Respond 2 (4%) |
Complicated 20 (38%) | Requires learning 47 (89%) Developing networked, cross-sectional collaborations with interprofessional teams able to design individualized treatment plans for newborns who had lost weight. | Manager and staff 13 (24%) Redesigning the physical space of the new obstetrics clinic by merging four units. Managers held the responsibility for changing the physical space and organizational structures and staff was responsible for developing and testing the new workflows and new patient pathways. | Technical and adaptive 32 (60%) Reduce admissions due to postpartum hemorrhage. The technical work involved raising the limit for how much bleeding could be accepted without having to admit the patient for further observation. This change was based on the realization that the previous limits were based on insufficient evidence. The adaptive work involve changing the “better safe than sorry” culture. | Sense Analyze Respond 4 (8%) | |
Complex 15 (28%) | Requires learning 15 (28%) How to redesign the physical space of the new obstetrics clinic that arose from the merger of four units to improve patient flow and coordination and collaboration across organizational and professional silos. | Staff > manager 37 (70%) Responsibility for development of the group B streptococcal (GBS) test to prevent unnecessary administration of IV-antibiotics and the subsequent unnecessary admission for observation was held by a senior physician. | Adaptive 18 (34%) Iterative approach to redesign the physical space and the flow of patients and staff in the obstetrical unit. | Probe Sense Respond 0 (0%) |