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Evidence scan: Complex adaptive

August 2010

Identify Innovate Demonstrate Encourage Contents

Key messages 3

1. Scope 4

2. 6

3. Sectors outside of healthcare 10

4. Healthcare 13

5. Practical examples 18

6. Usefulness and lessons learnt 24

References 28

Health Foundation evidence scans provide to help those involved in improving the of healthcare understand what research is available on particular topics. Evidence scans provide a rapid collation of empirical research about a topic relevant to the Health Foundation's work. Although all of the evidence is sourced and compiled systematically, they are not systematic reviews. They do not seek to summarise theoretical literature or to explore in any depth the concepts covered by the scan or those arising from it. This evidence scan was prepared by The Evidence Centre on behalf of the Health Foundation.

© 2010 The Health Foundation Previously published as Research scan: Complex adaptive systems Key messages

Complex adaptive systems thinking is an approach that challenges simple cause and effect assumptions, and instead sees healthcare and other systems as a dynamic process. One where the and relationships of different components simultaneously affect and are shaped by the .

This research scan collates more than 100 articles The scan suggests that a complex adaptive systems about complex adaptive systems thinking in approach has something to offer when thinking healthcare and other sectors. The purpose is to about leadership and organisational development provide a synopsis of evidence to help inform in healthcare, not least of which because it may discussions and to help identify if there is need for challenge taken for granted assumptions and further research or development in this area. prompt people to think in a less linear fashion. The key topic areas covered are: The most commonly suggested advantages of this approach are that it: –– How has complex adaptive systems thinking commonly been defined? –– challenges assumptions –– How has this approach informed leadership and –– focuses on relationships rather than simple cause organisational development in various sectors? and effect models –– How has this approach been applied in the –– can be applied in a of contexts health context? –– provides a framework for categorising and –– What practical initiatives use this approach? analysing knowledge and agents –– How useful is this way of thinking? –– suggests new possibilities for change –– provides a more complete picture of forces The quantity and quality of research available is affecting change limited. Frequently cited caveats include: Quality of evidence Relevance to priorities across the UK –– not well defined or differentiated –– lack of empirical testing and use Potential for use of this to have –– lack of comparison with other real patient and cost outcomes –– lack of predictive value Quantity of evidence available overall –– used to justify a lack of intervention. Quality of evidence available overall Availability of other evidence There may be a need for a clearer definition of summaries and guidelines this approach and how it applies to healthcare, comparisons with alternatives and empirical exploration of its value because most of the information available is descriptive rather than solid research.

Complex adaptive systems 3 1 Scope

The scan provides a rapid collation of empirical research about complex adaptive systems thinking. Although all of the evidence has been sourced and compiled systematically, it is not a systematic review and does not seek to summarise theoretical literature or to explore the concepts of complex adaptive systems in any depth.

1.1 Purpose The incorporated material from many different disciplines and included MEDLINE, This research scan summarises readily available Ovid, Embase, ERIC, the Cochrane Library and research studies about or using complex adaptive Controlled Trials Register, PsychLit, HealthStar, systems thinking, with an emphasis on how Google Scholar, the WHO library, Health complex adaptive systems models have been Information Consortium and Sigal. used to inform leadership and organisational All databases were searched from inception development approaches. until present. Mesh terms and expanded key word searches were used based around the terms The key topic areas covered are: , whole systems, adaptive leadership, –– How has complex adaptive systems thinking working whole systems, and complex adaptive commonly been defined? systems. –– How has complex adaptive systems thinking To be eligible for inclusion in the review, studies been used to inform leadership and had to be: organisational development in various sectors? –– How have complex adaptive systems approaches –– primary research or reviews been applied in the health context? –– published research –– What practical initiatives have used complex –– readily available online, in print or from relevant adaptive systems approaches? organisations –– How useful is complex adaptive systems –– available in abstract, journal article, or full thinking? report form This section outlines the methods used to collate –– address one or more of the core questions. information. The following sections address each of the questions above briefly in turn. Studies in any were eligible for inclusion. We scanned more than 50,000 pieces of research, 1.2 Methods selecting the highest quality and most relevant To collate evidence, one reviewer searched 10 to summarise here. No formal quality weighting bibliographic databases, reference lists of identified was undertaken within the review, apart from articles and reviews, and the websites of relevant the selection process outlined above. More than agencies for information available as at July 2010. 100 of the highest quality studies and descriptive The search, analysis and narrative synthesis were overviews were synthesised. completed over a three week period.

4 THE HEALTH FOUNDATION Data were extracted from all publications using There is a paucity of comparative a structured template and studies were grouped according to topic areas and outcomes to provide evidence so it is difficult to say whether a narrative summary of key trends. Meta-analysis complex adaptive systems thinking is was not appropriate given the context of the review more or less effective than alternatives. and the heterogeneity of the material. No other detailed empirical reviews specifically on this topic Third, the empirical evidence did not usually were identified. focus on defining the approach and terms such as ‘complexity theory’ and ‘complex adaptive systems’ When interpreting the findings it is important to were sometimes used interchangeably. This means bear in mind several caveats. First, the review is there is a lack of specificity and consistency not exhaustive. It presents examples of studies and surrounding the material included. interventions but does not purport to represent every study about complex adaptive systems It is important to remember that a lack of evidence thinking. does not indicate a lack of effect or that theories or interventions are ineffective, just that there may Second, it is difficult to draw conclusions about the be few high quality studies available from which to usefulness of this approach given the paucity of draw conclusions. empirical research. Even where empirical studies were available, the level of detail was sometimes These caveats are all important when considering insufficient to provide a meaningful summary. the synthesis of material overleaf.

Complex adaptive systems 5 2 Concepts

This section describes some of the ways that complex adaptive systems thinking and similar concepts have been defined and the principles or characteristics of the approach.

2.1 Defining complex Some planners and analysts have suggested that many things remain unpredictable and need adaptive systems new styles of analysis, including the , In its most simple form, complex adaptive , immune systems and organisational systems is a way of thinking about and analysing and human behaviour. things by recognising complexity, and In the of quantum , researchers found interrelationships rather than focusing on cause that the very smallest sub nuclear particles were and effect. behaving according to a different of rules, The term ‘complex adaptive systems’ is thought not cause and effect. Investigators from many to have been coined in the 1980s at the different disciplines began to explore phenomena interdisciplinary , a New Mexico in similar ways and a new theory emerged known think tank. However, this type of thinking has as ‘complexity theory.’ Complexity theory is based been around for some . For instance, in the on relationships, emerging patterns and iterations. 19th century the of It suggests that the is full of systems described how order in systems is such as weather systems, immune systems and spontaneous (or emergent) and is not necessarily social systems, and that these systems are complex planned. In the 20th century the study of complex and constantly adapting to their . phenomena was further applied to human Over the past decade or so, this way of thinking economics, , , , about systems has become known as the complex and the natural . Over the adaptive systems approach. past decade or so, the concepts have started to be The most common definition of a complex adaptive used more extensively in healthcare, education and system, based on the work of John Holland, is 1,2 the social sciences. a dynamic network of agents acting in parallel, Proponents of this way of thinking suggest that constantly reacting to what the other agents are in the past researchers and planners have viewed doing, which in turn influences behaviour and the 4 things in linear teams with simple rules of cause network as a whole. Control tends to be dispersed and effect. Analysts saw the world, organisations or and decentralised and the overall behaviour of their subject of study like a machine and thought the system is the result of many decisions made 5 that if they took the machine apart and understood constantly by agents. Following the components, then they would understand the work around neural networks, it is thought in a whole. It was also assumed that if each part was complex order emerges rather made to work better, then the whole would also than being predetermined. It is not possible to work better. 3 reverse the system’s history and the is often unpredictable.6

6 THE HEALTH FOUNDATION Others have defined this model as the study of Others use the terms ‘complexity’ and complex how relationships between components give adaptive systems interchangeably because the rise to the behaviours of a system and principles are thought to be similar or synonymous how the system interacts and forms relationships or because there is a lack of understanding about with its environment. Other definitions focus any differences between the two. on more physical components, such as seeing The term ‘complex adaptive systems’ is used complex adaptive systems as collections of simple throughout the scan for consistency but it is interacting units that have the ability to evolve to acknowledged that some authors use ‘complexity fit a changing environment. theory’ instead to describe the same principles. Complex adaptive systems thinking challenges This way of thinking is not a single theory because some of the assumptions that policy makers, it includes more than one theoretical framework planners and researchers may take for granted and is interdisciplinary in . when interpreting things. These assumptions include:7 For convenience, this scan uses the terms theory, approach, model and way of thinking to describe –– that every observed effect has an observable the throughout, but it is acknowledged cause that the concept is not unilateral in nature and has –– even the most complicated things can be many different definitions and approaches. understood by breaking down the whole into pieces and analysing it –– that if we analyse past events sufficiently, this 2.2 System components will help to predict future events.

These assumptions have been used when studying Complex adaptive systems thinking suggests that the physical world but proponents of complex the agents in any system are all the components adaptive suggest that they have of that system and interact and connect with each served less well when exploring how other in unpredictable and unplanned ways. For of people interact and behave. Phrases such as instance, air and water interact in a complex adaptive systems, complexity , weather system and plants and animals interact in complexity theory and complex evolving systems an . are often used interchangeably. Some theorists suggest that complex adaptive systems thinking is a This model that all of the interactions subset of complexity theory or vice versa.8 within systems begin to form emerging patterns which in turn feed back into the system and Complex adaptive systems [occur further influence the interactions of the agents. where] complex and patterned output Figure 1 (page 8) provides a visual representation arises from simple, fundamental of this process. For clarity the process principles, but requires many actors appears outside the system, but according to the and multiple interactions over time to model it is an integral part of the system itself. produce the emergent complexity. Yet, There is no simple or most commonly used this characterisation represents only a definition of complex adaptive systems, but this sample of the myriad of different facets of model of thinking tends to be guided by principles complexity.9 and components listed on the following pages.

Complex adaptive systems 7

Feedback Feedback

Regularities

Agents

Figure 1: simple representation of the components of a complex adaptive system10

2.3

The characteristics of complex adaptive systems The agents in the system interact in apparently include: random ways but from all of these interactions patterns emerge which ultimately inform and –– a large number of elements which interact change the behaviour of the agents and the system dynamically itself. –– any element in the system is affected by and affects several other systems Co- –– non linear interactions, so small changes can have large effects Systems are part of a broader environment so –– openness, so it may be difficult to define system as the environment changes, systems change to boundaries ensure best fit. This in turn influences the wider –– a constant flow of to maintain the environment, and creates a constant cycle of organisation of the system change as the system develops to adapt to the –– a history whereby the past helps to shape present environment and the environment changes as behaviour a result of system alterations. Some theorists –– elements in the system are not aware of the distinguish between ‘complex adaptive systems’, behaviour of the system as a whole and respond which continuously adapt to the changes around only to what is available or known locally. them but do not learn from the process, and ‘complex evolving systems’, which learn and evolve According to the literature, complex adaptive from each change and thus help influence their systems have a range of properties, including those environment, predict likely changes and prepare described on the following pages. accordingly.

8 THE HEALTH FOUNDATION Others do not draw any distinction and instead Self organising suggest that ‘adaptive’ systems are also able to learn. Complex adaptive systems do not have a of command. They constantly This signals that the Health Foundation and other reorganise themselves to find the best fit with the organisations may need to consider the value environment. of using terminology such as complex evolving systems versus complex adaptive systems as a way Edge of of conceptualising leadership and organisational Complex adaptive systems thinking is not exactly development. the same as , which is derived from Connectivity , although there are some overlaps. Systems range from equilibrium to chaos. Those How agents in a system connect and relate to one systems which are not able to respond to their another is critical to the system’s survival and so environment will cease to exist. Thus a system in the relationships between the agents are usually chaos ceases to function as a system. Complex seen as more important than the agents themselves adaptive theory suggests that the most productive in complex adaptive systems thinking. state for a system is the ‘’ where there is maximum variety and creativity. Nested systems Based on these properties it could be argued that Most systems are embedded within other systems. complex adaptive systems are all around us, or that For example, a hospital is a system in itself with we are part of multiple complex adaptive systems. staff, patients and carers, suppliers, partners, commissioners and neighbours. The hospital also Principles such as self organisation and emergence belongs to a wider health system within its town or are what distinguishes a SHA region and the larger system of the NHS. from other multi-agent systems, which are merely systems composed of multiple interacting agents. Simple rules In complex adaptive systems, the agents as well as the system are adaptive. Complex adaptive systems are not complicated and are often governed by simple principles. Examples of complex adaptive systems may include Iteration the NHS, individual hospitals and healthcare organisations, communities, political parties, the Small changes within a system can build like a , the , colonies, the snowball, leading to larger change. market, the ecosystem, developing , and any human endeavour. However, Sub optimal some might argue that not all of these things share every characteristic of complex adaptive systems. Complex adaptive systems do not have to be Of the empirical studies investigated within the perfect and some suggest that any energy used scan, few of the systems neatly or unquestioningly on being much better than alternatives is wasted corresponded to all of the properties listed here. energy. Requisite variety

Complex adaptive systems thinking suggests the greater the variety within the system, the stronger it is, and the more likely it is able to create new possibilities and co-evolve.

Complex adaptive systems 9 3 Sectors outside healthcare

This section briefly outlines selected examples of how complex adaptive theory has been used to inform thinking about leadership and organisational development in a range of sectors outside healthcare services.

3.1 Using complex adaptive Economics theories in other sectors Researchers have examined whether complex adaptive systems thinking can help explain the The descriptive literature is extensive so only characteristics of market organisation and the roles a selection of available material is included for of leaders and others within this. For instance, illustrative purposes. Rather than describing researchers in developed to test leadership and organisational development whether economic systems will self regulate to in a narrow sense based on management or gain the most efficient state of resource allocation. , a much wider range of literature They found that efficient allocation of resources about organisational and system improvement is can occur despite a lack of described to give a flavour of varied topics covered. among participants and used principles of Much of the published literature available complex adaptive systems thinking to explain the about complex adaptive systems thinking is not underlying reasons.12 empirical. There are numerous articles describing Management the perceived pros and cons of complex adaptive systems approaches and postulating how this Complex adaptive systems thinking has been used model may apply in various spheres such as to investigate leadership styles, organisational management, psychology, , change, team dynamics and .13-16 the physical sciences, education and healthcare. For instance some authors have argued that in These descriptions are based on the opinions and order to be sustainable when there is no central analyses of the authors rather than grounded in provision of resources, organisations need to empirical research. This research scan is focused on have autonomous workers and staff that are fully empirically based material. integrated into the organisation. A comparison of four different pharmacy districts in the USA based on interviews, staff questionnaires and balanced Writers have examined how complex adaptive scorecard indicators found that comparing the systems might be used to understand the structures autonomy and integration of systems was a useful and properties of objects and the people who way to understand variation. The author concluded use them. Much of this work is descriptive or that decentralised resource generation is one theoretical, rather than applying the concepts way of obtaining sustainability. The coexistence to leadership or organisational development of autonomy and integration of employees, plus practically.11 transformational leadership all encourage this.17

10 THE HEALTH FOUNDATION A literature review and case study in the USA capacity for monitoring and responding to examined how managing organisations could environmental feedback; information flow through be analysed using complex adaptive systems social networks; the combination of various thinking. Useful management features were found sources of information and knowledge; and sense- to include a clearly formulated mission, delegation making and arenas of collaborative for of responsibility and authority, diversity and ecosystem management.21 , and follow up and feedback.18 Researchers in the USA examined the best form A number of management articles have explored of leadership for advancing the integration of the concept of ‘adaptive leadership’, which conservation science into policy, management and recognises and draws on the concepts of complex at large. adaptive systems thinking. A study in Taiwan Adaptive leadership principles were used to evaluated the impact of leadership styles on identify essential traits including recognising the of high industries. the social of the problem; cycling It examined the impact of adaptive and non frequently through action and reflection; getting adaptive leaders on six measures of productivity: and maintaining attention; combining the absenteeism, staff turnover rate, quality of work, strengths of multiple leaders; extending reach reject rates, profitability and units produced. In through networks of relationships; strategically line with complex adaptive systems thinking, the timing efforts; nurturing productive conflict; and researchers found that the greater the level of cultivating diversity.22 adaptability, the more productive the organisation is likely to be.19 Education

Urban planners Complex adaptive systems thinking is gaining increasing popularity and there are numerous A case study in Canada found that complex examples of how this model has been applied to adaptive systems approaches add value over help analysts think differently.23-27 For instance, traditional accounts of and healthy authors in the US used a range of leadership cities movements. In particular, the authors theories to examine the role of school nurses. concluded that this way of thinking opens up They concluded that school nurses can use fresh possibilities for improving health in urban transformational leadership, situational leadership contexts.20 and complex adaptive systems thinking to create Environmental scientists positive change in the school environment because all of these models recognise the need for flexible Examples have been described from Sweden and leadership. Complex adaptive systems thinking Canada regarding the development of adaptive also recognises the sometimes chaotic nature of co-management systems. They showed how the school setting, which requires organisational local groups self organise, learn and adapt to and leaders to be flexible and to identify and address its shape change with social networks that connect changing needs.28 institutions and organisations. The authors found that institutional and organisational landscapes A recently published qualitative study examined should be approached as carefully as ecological the implementation of health promotion factors in order to identify features that contribute programmes in primary schools in Australia. to the resilience of social-ecological systems. These Complex adaptive systems thinking was used as a features include vision, leadership, and trust; framework to help understand the ways in which enabling legislation that creates social for interventions could be introduced and sustained. ecosystem management; funds for responding to The authors examined whether schools exhibit environmental change and for remedial action; characteristics of complex adaptive systems and

Complex adaptive systems 11 suggested that schools have most, but not all of the In the USA, RAND described using complex characteristics of such systems and have significant adaptive systems thinking as a tool for policy differences to artificial and natural systems. The analysis. The focus was on predicting which authors concluded that understanding schools policies will perform well, but this is somewhat as social complex adaptive systems may help to at odds with the concept of complex adaptive explain some of the challenges of introducing thinking approaches that tend to focus on and sustaining change which in turn could help description and analysing possibilities rather than implement more sophisticated approaches to the predicting effectiveness.31 This is an example of diffusion of new programmes.29 how the theory may be adapted and applied very differently from what might be expected from core A range of generic material is also available definitions. describing the potential role of complex adaptive systems in understanding leadership 3.2 Summary and organisational development. This material is not necessarily grounded in a particular Quality of evidence Low discipline and most is descriptive or opinion Quantity of evidence Low orientated. For instance, US authors examined how organisations respond to surprise and why Key points surprise or uncertainty occurs. They suggest that complex adaptive systems theory helps to Complex adaptive systems thinking has been explain the challenges organisations face and that used to examine organisations and leaders in a creativity and learning are two strategies to help number of fields. Education and management organisations deal with surprise.30 are the two fields outside health with the highest proportion of empirical research, but more theoretical descriptions are prevalent throughout other disciplines. Most of the available material is descriptive rather than research based.

12 THE HEALTH FOUNDATION 4 Healthcare

This section describes how complex adaptive systems thinking has been applied in the context of healthcare in the UK and internationally. The focus is on briefly describing the range of topic areas to which this approach has been applied. Examples of practical implication are provided in the following section.

4.1 Leadership and Authors in the USA have analysed leadership for change as an ‘activity’ rather than a management of formal authority and focused on the beliefs, A number of authors have espoused the value attitudes, and culture necessary to support adaptive of leadership styles which use the principles leadership. Resistance to change is described as of complex adaptive systems thinking to make a reaction to loss, which needs to be addressed positive changes by influencing context and through leadership activity and engagement. relationships.32 In order to sustain change and , it is argued that leadership must be less accidental, less In Sweden, authors suggest that complex adaptive technical and more adaptive.35 systems thinking could potentially help leaders to understand why the traditional top down It has been suggested that complex adaptive way of managing may difficulties in systems thinking is useful for helping to interdependent organisations with complex tasks. understand clinician leadership as well as managerial leadership and can be applied to many When we perceive health and social different facets of healthcare, from psychology services as complex adaptive systems and mental health services through to biology and we should gain more insight into the neurology.36,37 Important skills for clinical leaders processes that go on within and between include self , shared authority, conflict organisations and how top management, resolution, and non punitive critique.38 for example within a hospital, in fact 33 executes its steering function. Researchers in the UK and elsewhere Researchers in the UK and elsewhere have have highlighted the importance highlighted the importance of connectivity, recursive feedback, diversity and self-ordering of connectivity, recursive feedback, rules when analysing how to manage health diversity and self-ordering rules when 34 services. analysing how to manage health services.

Complex adaptive systems 13 4.2 Organisational evolving relationships and dynamic interactions. development Examining global health governance through the frame of complexity theory It has been suggested that systems that do not offers insight into the current dynamics understand the principles of for complex adaptive systems continue to apply of governance, and while providing change models that have little chance of success. a framework for making meaning of Understanding the principles and actions that the whole, opens up ways of accessing enable change in complex adaptive systems may be this complexity through local points of 44 ❋ essential for long-term success.39 engagement. Healthcare organisations have been described as Theorists have applied complex adaptive systems macro systems comprised of micro systems. Some thinking to support change in healthcare.45,46 have argued that this means that management For instance, researchers from the USA suggest actions can no longer be based on linear thought that there are significant barriers to providing patterns or PDSA cycles. Instead, action must be universal healthcare coverage, including economic, innovative and based on the advantages of micro legal, cultural and barriers. Using systems and how they interact with the wider complex adaptive systems thinking, they postulate health macro system. This emphasises that the a range of prerequisites for achieving significant scope for positive change can start small, and reform, including the existence of large and snowball out to the rest of the adapting system.40 enduring social forces to disrupt legislative and Researchers undertook a to consider policy stasis and a political ‘tipping point.’47 whether the characteristics of primary care In the UK, complex adaptive systems theory has practices in the USA could be understood as been used to provide insights about the importance complex adaptive systems. They concluded that it of involving lay researchers as co-producers is useful to conceptualise primary care practices as of knowledge and to explore how complex adaptive systems consisting of a core (a regeneration and other environmental influences practice’s key resources, organisational structure, can impact on health and healthcare.48,49 and functional processes), adaptive reserve (practice features that enhance resilience, such 4.3 Workforce development as relationships), and attentiveness to the local environment.41 The authors argued that successful Analysts have also applied this model to examine practice development begins with changes that the roles and interrelationships of different parts strengthen practices’ core, build adaptive reserve of the healthcare workforce, particularly nursing, and expand attentiveness to the local environment. primary care and rehabilitation teams.50,51 Some A number of other authors have also proposed the believe that complex adaptive systems thinking value of complex adaptive systems thinking for can be motivating because it stresses that the most analysing and improving primary care.42,43 powerful processes begin with the staff, at the micro level of an organisation.52 On a broader level, there has been an increasing move to examine international or global health This model has been used to understand general and healthcare rather than solely defining practitioners’ roles in self organising local networks organisational change in narrow terms. Some have in Canada, focusing on the capacity to generate argued that global health governance shares the new solutions based on historical and social characteristics of complex adaptive systems, with connections.53 multiple and diverse stakeholders, their constantly

❋ This quote is an example of using the term ‘complexity theory’ somewhat interchangeably with ‘complex adaptive systems.’ A number of 14 THE HEALTH FOUNDATION similar examples occur in quotes throughout this report. In the USA, a number of articles have been stereotyping, communities of practice, reflective published which seek to help clinicians understand learning and transformative learning guide specific complex adaptive systems and apply this way of educational interventions. Thus, according to thinking to support their practice. this research, complex adaptive systems thinking may be one of many approaches needed when Physicians need to learn to expect considering organisational development, leadership unpredictability, respect autonomy and and education in healthcare. This suggests that creativity, and be flexible in responding rather than being the only underpinning analytical to emerging patterns and opportunities. tool, it may be most effective as one among many Assessing and managing complexity in theories in an organisation’s armoury.58 the health care environment involves understanding why medical practice is a 4.4 Service delivery complex adaptive system and how to work A number of authors have considered the value of within such a system to achieve the best complex adaptive systems thinking for analysing 54 outcomes. healthcare service delivery.59,60 For example, A range of work has also been undertaken about writers from Australia conceptualised healthcare pre-registration education for the healthcare consultations as a complex adaptive system workforce, though most of this is descriptive rather whose characteristics are not determined by the than empirical.55,56 For instance, in Scandinavia an characteristics of the components, but by the education programme for undergraduate dentists patterns of among the components. has been developed. The authors suggest that taking time to develop memories within the consultation process is The model describes the oral cavity in a complexity essential. The dynamics between the participants in based ecological context, suggesting that factors the consultation will create shared memories that from different organisational levels (biological, live on to shape future interactions 60 individual, community, society) interact in a complex way with the potential to ‘stress’ the In the USA, researchers used complex adaptive ecosystem and thereby provoke changes. The oral systems theory to understand the effect on safety of cavity is seen as a complex adaptive system.57 introducing electronic medical records in primary care. Each primary care practice can be viewed Analysts in Canada have examined the benefits as a with unique characteristics. of complex adaptive systems thinking when Introducing an electronic medical record into such interpreting interprofessional collaboration and a system could have unpredictable effects, and communication in healthcare, including initiatives may increase safety in some areas and increase aimed at enhancing patient safety and preventing vulnerabilities in others. medical errors. In contrast to approaches which educate each discipline in isolation, A rural primary care practice applied a Failure interprofessional education of health professionals Modes and Effects Analysis (FMEA) based on the focuses on creating knowledge largely through concept of hazard adapted from safety engineering. interactions with others. The authors suggest that Hazard scores were used to prioritise the safety social psychology and complexity theory can be problems within the practice and checked again used to explain the influence of dynamism and one year later, after partial implementation of an interaction of internal (cognitive) and external electronic medical record. The authors suggest this (environmental) factors upon learning, but more may be a useful method for targeting new and pre- 61 specific theories related to professionalism and existing safety concerns in primary care practices.

Complex adaptive systems 15 Writers from Canada suggest that long-term chaotic indefinitely. However the author notes that conditions and chronic care can be usefully there are more theoretical articles about applying conceived as a complex adaptive system. The this concept to organisational behaviour than widely used Chronic Care Model is often limited empirical studies and as such the value of applying when applied in practice because there is a focus this theory to organisational development in on discreet chronic disease interventions in specific physical and social psychology remains somewhat settings. untested.70 The notion of ‘complex adaptive chronic care’ Psychoanalysts have examined how this model may has been proposed as an explanatory framework. apply to a range of therapies, in particular group This includes seeing chronicity itself as a journey, therapy. Features of group therapy which lend with simple and complicated phases, that affects themselves to comparison with complex adaptive , families and communities. systems include non linear , self organisation, co-evolution and disequilibrium.71 Using this type of systems approach to optimise care for people with long-term conditions aims Writers have also examined assertive community to build on local visions of health, empower treatment for people with severe mental illness as individuals, support adaptive leadership, and a complex adaptive system which engages in the be responsive to local values and history. It is organisational processes of ‘sense-making’ and self suggested that this model is helpful because: organisation.72 The awareness of complexity means 4.5 Behaviour change opening up problems to a different demanding different sets of questions and Some suggest that rather than seeing health approaches to answer them.63 behaviour change as a linear cause and effect model, this is better understood through the lens of Similarly, it has been suggested that understanding complex adaptive systems. primary care clinics as a complex adaptive system may enhance delivery of a flexible supportive Using this model implies that behaviour change process for people with dementia and that this may be a process that is highly variable and difficult model also holds value for the development of to predict, and occurs within a complex adaptive maternity services, obesity, patient safety, and system with multiple components, where results 73 organisational mergers.64-68 are often greater than the sum of their parts. Furthermore, complex adaptive systems thinking It has also been suggested that patients and families and complexity theory has been used to examine can be understood as complex adaptive systems. In components of the National Programme for IT this view, understanding the non linear dynamics in England, including the value of Choose and of features internal and external to patients Book.69 can improve how health is defined; enhance professionals’ understanding of patients, disease Focusing on the psychological sciences, a review and the systems in which they converge; help to of concepts such as ‘chaos’ and ‘complexity’ in develop future monitoring systems and be used to , psychophysics, psychomotor skills, support change.74 learning, clinical and abnormal psychology, and group dynamics and organisational behaviour 4.6 Clinical analysis found that the concept of complex adaptive systems has become a popular way to explain how A significant number of studies have used complex human systems self organise rather than staying adaptive systems thinking to analyse physical

16 THE HEALTH FOUNDATION properties such as the immune system or specific health conditions.75,76For instance researchers in Mexico conceptualised fibromyalgia as a failed attempt of the body’s main complex adaptive system (the autonomic ) to adjust to a hostile environment. They suggest that fibromyalgia cannot be understood fully using prevailing linear-reductionist medical models and that complex adaptive systems thinking can help to explain the causes and effects of this condition, and points towards the need for holistic therapies.77 4.7 Summary

Quality of evidence Low Quantity of evidence Medium Key points

There are a number of examples of how complex adaptive systems thinking has been applied in healthcare. The concept has been used much more widely to explore service delivery than in leadership and organisational development.

Complex adaptive systems 17 5 Practical examples

Empirical examples of how complex adaptive systems thinking has been applied are less common than theoretical overviews or opinion pieces. This section describes some of the empirically based healthcare literature specifically related to leadership and organisational development.

5.1 Leadership and staffing Consistent with complex adaptive systems thinking, the main drivers for managerial Although a great deal has been written about the development were thought to be characteristics of potential theoretical value of complex adaptive the people involved (their motivation, leadership systems thinking for healthcare leadership, and commitment; the quality of relationships practical applications are much more sparse. among the main actors) and how the resources dedicated to manage change are used. The A survey in the USA found that healthcare leaders authors concluded that leaders and change agents intuitively support the principles of complexity should consider the management of relationships science. The authors argue that building on the with professionals as a key success factor for principles of complex adaptive systems thinking implementing change. They argued that managerial can help leaders focus less on prediction and leadership should be vertically and horizontally control and more on fostering relationships and diffused throughout organisations.80 creating conditions so systems can evolve and produce creative outcomes.78 Some have begun to view nursing homes as complex adaptive systems. For instance, a Promoting effective communication and qualitative case study in the USA described the overcoming the that conflict is ‘bad’ are leadership and working conditions in two high key challenges for leaders. A complex adaptive performing and two low performing nursing leadership model was applied to help perioperative homes. The authors suggest that using complex nurse leaders provide optimal care at one hospital adaptive systems thinking added richness to the in the USA. This encouraged managerial and analysis and highlighted differences between clinical leaders to assess the culture in which the high and low performing nursing homes. they worked and develop strategies to build solid Leaders in high performing homes behaved relationships within their teams. There were congruently with the nursing home’s stated improved surgical outcomes after one year.79 mission by supporting connectivity among staff Studies of leadership traits are often interlinked and ensuring ample information flow. Leaders in with research into organisational development. For low performing homes behaved at odds with the instance, researchers in undertook case study stated mission which confused and eroded trust interviews to understand which internal drivers and relationships among staff and contributed to in primary care explain and foster organisational poor communication, role isolation and a lack of change. continuity of care.81

18 THE HEALTH FOUNDATION Staff turnover of leaders and frontline staff in Rigorous reporting and testing of process nursing homes can impede quality. Researchers and staff motivation and interactions in the USA used complex adaptive systems drove innovation. Hundreds of clinical and thinking to test the effect of administrative , administrative staff at all levels were encouraged communication patterns and the interaction to redesign processes and roles to increase between the two on staff turnover, based on a organisational capacity. Capacity increased and survey of 3,449 employees from 164 randomly this approach was cost effective. The authors sampled nursing homes. concluded that complex adaptive systems thinking Climate and communication both affected can be used to encourage multiple, coordinated, turnover. The authors concluded that whilst wider and concurrent projects that will create a greater contextual issues are important, managers can impact than what would be possible with a single also influence turnover by addressing climate and improvement project.84 communication patterns and by encouraging stable It can be difficult to manage capacity in hospitals nursing leadership.82 and A&E departments. A case study in the USA As well as a limited number of practical studies described how an efficiency model was applied of leadership, research is also available about to an acute hospital facing a budget shortfall the types of staff development and networks as a result of capacity constraints. ‘Swarmware’ that leaders could encourage. Researchers in is an approach used in some complex adaptive Wales used complex adaptive systems theory to systems models to help examine system demand explore how knowledge is captured and diffused and interactions. Using a swarmware approach at a clinical level. Interviews with healthcare helped the hospital create additional bed capacity, practitioners and managers at one hospital trust accommodate demand and improve .85 This found that communication and interdependent is a very practical example of how a component working practices are built around networks and of complex adaptive systems thinking was applied collaborative multidisciplinary communities which practically in a healthcare context. support knowledge capture and adaptive learning. Similarly, in the West Indies, complex adaptive Characteristics of such as rational systems thinking was used to build a model for legal authority, a rule based culture, hierarchical change in the emergency department. Discrete lines of communication and centralised event was used to examine patient governance hinder clinical learning by generating flow. The simulation showed that a minor rotation barriers. The authors concluded that leaders among the nurses could significantly reduce the should nurture a collaborative infrastructure using number of patients that had to be redirected networks.83 to other parts of the hospital, thus resulting in significant efficiencies and improvement in patient 5.2 Development and delivery experience.86 A number of studies have explored the value Case studies with five health boards in Scotland of complex adaptive systems thinking on examined using complex adaptive systems thinking organisational development and service delivery. to implement and analyse whole systems change. A collaborative approach helped organisations move For instance, a US hospital used complex adaptive towards a culture of mutual understanding and systems thinking to grow organisational capacity greater awareness of interdependencies within the and cope with unexpected surges in demand for hospitals, which in turn improved patient flows. services. Seventeen improvement projects were However, it was difficult to address relationships implemented over a two-year period. Using a with the stakeholders that influenced out of complex adaptive systems approach, improvement hospital patient flows. The authors concluded that ideas ‘emerged’ from microsystems at the point of the programme improved performance by focusing care.

Complex adaptive systems 19 on interdependencies within a large part of the Using an analytical model based on complex acute care subsystem but did not have the same adaptive systems thinking, the authors explored impact at the overall healthcare system level - so why Bosnia and Herzegovina managed to roll out more work is needed to understand what influences significant reforms to over 25% of the country even whole system impacts.87 though many other countries struggled with the introduction of primary care reforms. There were Researchers in England described a programme important interrelationships between the initiatives, designed to bring about change in the performance adopters and the context. The perceived benefits of health visitors and school nurses in an inner of the innovation were an important influencer, primary care trust as a case study of professional including benefits to patients, doctors, nurses and and organisational change. Using a complex policy makers. Assimilation and implementation adaptive systems approach, change was seen as of the new primary healthcare model relied on an inclusive, evolving and unpredictable process. the consensus of a diverse group of stakeholders Using this theory influenced the development of the which created a ‘receptive context’ for adoption and programme, its implementation and outcomes. diffusion of the innovation.89 The programme was associated with extensive In South Africa, primary care is provided by nurses change in professional behaviour, service delivery in small clinics and larger community health and transformational change in organisational centres which also employ doctors. However, structures and processes. There were opportunities doctors often work in isolation from the nurses, for experimentation and innovation, but this with poor differentiation of roles and little also created uncertainty and the need for risk teamwork or communication. One community management for practitioners. health centre embarked on an improvement Using a complex adaptive systems programme to introduce practice teams, drawing approach was helpful for developing on the principles of complex adaptive systems. alternative views of change and for Important factors when implementing changes understanding why and how some included the amount of interaction, type of aspects of change were more successful communication, team resilience, staff satisfaction, leadership style, reflective capacity, experimentation than others. Its use encouraged the and evolution of new structures. Seeing the confrontation of some long standing organisation as a living system where information assumptions about change and service flow, participation and resilience are key aspects delivery patterns in the National helped to develop more effective change strategies. Health Service, and the process exposed challenging tensions within the The authors concluded that: Service. The consequent destabilising of organizational and professional norms If managers of the health system wish to resulted in considerable emotional impacts enhance organisational change, then their for practitioners, an area which was found goal may need to shift from optimising to be underplayed within the complex health care delivery in a mechanistic adaptive systems literature.88 model to optimising health care workers in a living system.90 Other researchers from England explored the introduction of primary healthcare in Bosnia and Leaders often attempt to make changes in Herzegovina, using qualitative and quantitative healthcare settings but find that interventions do methods over an 18-month period in 2004–5. not as expected. Unexpected outcomes are often attributed to variation or error in implementation processes.

20 THE HEALTH FOUNDATION But researchers in the USA used complex In England, principles from complex adaptive adaptive systems thinking to suggest that systems theory guided the development and unanticipated intervention outcomes can arise of an interdisciplinary education because unexpected conversations emerge during programme for undergraduate medical students. intervention attempts. Analysis of data from 14 The intervention included a staff training years of research about making change in primary programme, e-learning materials and care practices found that conversation between interprofessional team working skills seminars. system and organisational members plays an 237 first year students attended. The intervention important role in the success of interventions to enhanced theoretical learning about team working, improve healthcare delivery. Conversation can enabled students to learn with and from each other facilitate success because interventions often rely and raised awareness about collaborative practice on new sense-making and learning so the authors and its effect on care delivery.98 suggest that the likelihood of success will increase if the role of conversation is considered in the A US case study applied a ‘multimethod intervention process.91 assessment process (MAP)’ (also known as the reflective adaptive process) to help understand and When quality is treated as something that arises improve primary care practice. Guiding principles from the relationships within and between for change included building an understanding healthcare organisations and systems, then of the practice’s vision and mission among the different contributors to quality can be investigated entire team, supporting learning and reflection and more effective strategies for improvement to help organisations adapt to and change, can be developed. An analysis of data from four recognising that tension and discomfort are large US National Institutes of Health funded essential and normal during change, and seeking studies aimed to understand the characteristics diverse perspectives to foster adaptability and new of relationships within primary care practices. insights.99 Trust, mindfulness, heedfulness, respectful interaction, diversity, task relatedness, and rich In the USA, up to one quarter of nurses’ time clear communication were important for practice is spent on administration and documentation. improvement. A model was developed to describe Researchers have explored the documentation how these characteristics work together and of nursing care from a complex adaptive interact with reflection, sense-making and learning system perspective and made practical changes by to influence quality outcomes.92 adopting a standardised nursing language.100 In the USA, planners used complex adaptive Complex adaptive systems thinking has also been systems thinking combined with a transformation applied to support people with specific conditions. innovation cycle to motivate small and large scale For example, many people with type 2 diabetes changes. The model proposed that transformation have suboptimal control of their blood sugar, requires fundamental changes in current blood pressure and cholesterol, which puts them underlying beliefs and assumptions and redesign of at greater risk of complications. A wide range the multiplicity of diverse and complex subsystems of research has suggested useful interventions that result in unpredictable aggregate behaviour to address these concerns but the best methods and outcomes. Using this style of thinking was for implementing and sustaining interventions found to motivate behaviour change and enhance remains uncertain. Researchers in the USA respect for the whole team.93 suggested that this may be because most strategies do not account for the complex adaptive system This model has also been used to learn lessons characteristics of the primary care setting. ‘Practice from implementing facilitation’ takes account of the way that people systems in hospitals and other healthcare interact within complex systems. contexts. 94-97

Complex adaptive systems 21 It creates time for learning and reflection by Other US researchers used an evaluation approach members of the team in each primary care clinic, based on complex adaptive systems to assess aiming to improve communication and promote the value of the ‘Aging Brain Care Medical an individualised approach to improve patient Home’ concept. By focusing on interactions and outcomes. relationships, the evaluators were able to describe changes to performance and processes in detail.105 A randomised trial in 40 clinics is underway to test whether using this approach will be beneficial.101 ‘Better Jobs, Better Care’ was a programme implemented in five US states to change policy A systematic review examined whether and management regarding the recruitment and organisational interventions that build on the retention of direct care workers. One project principles of complex adaptive systems thinking developed an approach which rewarded skilled improve outcomes for people with type-2 diabetes. nursing, home care, and assisted living providers Of the 32 studies included, most used at least for meeting standards of workplace excellence. one complex adaptive system characteristic A case study was used to document the complex in their intervention designs and 91% were adaptive system agents and processes that helped to deemed to be effective or have mixed effects. The make this project successful.106 greater the number of complex adaptive system characteristics present in each intervention, the Researchers in England used complex adaptive greater the effectiveness. Interconnections between systems thinking to explore why the effect of a participants and co-evolution were most likely to single intervention incorporated into a complex be associated with success.102 clinical environment may be different from what is expected. Demographic and health information Some suggest that complex adaptive systems were collected from all patients admitted to a UK thinking is an intangible concept that offers little hospital between January 2003 and June 2004. for health services research or development. But Continuous process monitoring was undertaken researchers in the UK developed a simple tool using charts to detect planned or unplanned to test the value of this approach for people with organisational process changes affecting mortality diabetes. They concluded that these principles outcomes.107 provide an interprofessional perspective for describing and understanding the processes Other researchers in England used complexity involved and can help shape practical ‘tools’ for principles to analyse waiting list data from patients, carers and practitioners.103 1998 to 2001 relating to more than 20,000 NHS patients from general surgical, orthopaedic and 5.3 Research and evaluation neurosurgical units across England. Using this analysis approach lead the authors to conclude that Complex adaptive systems thinking has been used the system may be at ‘the edge of chaos’ and this as an analysis approach in a number of studies. For could explain why waiting have been difficult instance, researchers in Texas tested the value of to reduce.108 complex adaptive systems thinking for explaining the relationship between management practices In New Zealand, complex adaptive systems (communication openness, decision making, thinking was used as an analytic tool to compare relationship oriented leadership and formalisation) two community based interventions. This approach and outcomes for nursing home residents provided a means of exploring local issues by (aggressive behaviour, restraint use and ), taking a whole system approach. The authors found using a cross-sectional survey with 164 nursing that this provided a dynamic picture of shared homes. Each management practice explained one influences on the interventions. The existence or more of the resident outcomes so the authors and capacity of local organisations and their concluded that complex adaptive systems thinking relationships with government agencies influenced was a useful explanatory device.104 the success of the interventions.109

22 THE HEALTH FOUNDATION Systematic reviewers from Canada used complex Complexity thinking develops adaptive systems theory to analyse trends in literature about interprofessional health and social an awareness of issues including service partnerships for chronic care. They outlined uncertainty, contextual issues, the value of a conceptual model about complexity multiple perspectives, broader societal for examining the relationships between frontline staff who provide care for people with long-term involvement, and . conditions.110 It is difficult to answer questions about what impact In the USA, researchers used modelling techniques using this theory had without knowing what to help understand the operation, organisation would have happened if complex adaptive systems and structure of the heroin market. Data from thinking was not used or what the outcome would an 18-month ethnographic case study was used. be if an alternative theory or analysis was used. The authors studied the behaviours of customers, The scan did not identify empirical comparisons private dealers, street sellers, brokers and the of complex adaptive systems theory versus other police. These methods may be a novel way to theoretical approaches. understand complex health behaviours and outcomes.111 5.4 Summary Researchers in the USA used complex adaptive systems thinking to inform the development of a Quality of evidence Low balanced scorecard model for a business unit in an Quantity of evidence Medium academic healthcare institution. Using the model Key points helped to develop process and outcome indicators that focus on how the work of all team members A small number of empirical studies are available 112 makes a difference to clinical services. about applying complex adaptive systems theory Others have explored the value of complex adaptive in practice, but this continues to grow. Most of the systems thinking for evaluating cost effectiveness studies have been published within the past five to and other economic indicators in healthcare. The 10 years. quote below is another example of how the term Without anything to compare with, it is difficult ‘complexity theory’ is often used interchangeably to draw conclusions about the extent to which here. using this theory influenced the success of the Complexity theory may provide a useful intervention or the analysis. However, the authors for economic evaluation of most studies suggested that using this model in healthcare. Complexity thinking develops had helped them to think more broadly when an awareness of issues including uncertainty, creating interventions or analyses or to focus more contextual issues, multiple perspectives, broader specifically on relationships than would otherwise 112 societal involvement, and transdisciplinarity.113 be the case. These examples show that complex adaptive systems thinking has been used increasingly frequently as an analysis and research development tool in healthcare, with favourable results.

Complex adaptive systems 23 6 Usefulness and lessons learnt

This section summarises the areas in which complex adaptive systems thinking has been useful and less useful. These conclusions are based on a review of the empirical research, not on other opinion pieces or analyses of the model, which are also prominent.

6.1 Challenging assumptions

Complex adaptive systems thinking is a way For instance, some applications of complex of challenging taken for granted assumptions adaptive systems thinking suggest that in order about how people, organisations and systems to change an organisation’s inertial momentum interact. Regardless of whether the way complex from an ethos of failure, a massive and sustained adaptive systems theory conceptualises the world intervention may be needed at every possible is applicable in itself, the mere fact that it pushes level until the phenomenon of learning excellence 116 planners and policy makers to think about their emerges and sustains itself. By moving away from assumptions and challenge their beliefs about a cause and effect model to focus on relationships, knowledge and learning could be seen to have it is argued that a clearer perspective about options some value. This allows policy makers and is available. researchers to consider deeper underlying causes [Previous] efforts assumed that and interactions than may have been the case with complicated phenomena could be more surface level assumptions. understood by analysing their constituent 6.2 Substantive features parts, when in fact the sum of the whole was greater, and more complex, than the It is more difficult to draw conclusions about the sum of the individual parts. Consequently, merit of the theory itself because few empirical reforms modified one or two elements studies have directly compared this way of thinking in a system apart from related elements, with others by applying two or more alternative assuming that these actions would theories to one topic area. produce the intended outcome through Some might argue that the underpinning principles a linear, cause-and-effect relationship... are reasonably common sense and so the main Complexity theory draws attention to the value of this way of thinking is its ability to see evolving interrelationships among system through taken for granted approaches and delve elements at various levels of the system. deeper into the way people and organisations It offers a means to analyse emerging interact. patterns and trends to illuminate how This approach is a model for thinking about the the disparate system parts are, or are not, 117 world, not a way of predicting what will happen. working together. Some authors suggest that thinking about things as complex adaptive systems opens up a variety of new options.115

24 THE HEALTH FOUNDATION In Australia, this way of thinking was used to We must accept that uncertainty and plan how to more effectively introduce health unpredictability are inescapable. This promotion programmes to schools. Viewing makes uncomfortable for managers, schools as complex adaptive systems helped but an understanding of how complex planners to consider the best way to introduce and adaptive systems work helps us explore sustain change. However, the authors noted that a range of management styles and schools did not contain all of the characteristics practices.123 commonly attributed to complex adaptive systems and were quite different to some other Studies suggest that the concept of complex environments in which this model had been adaptive systems is sometimes difficult to implemented.118 understand, but can be helpful in identifying the dynamic nature of organisations.124 This Some have argued that this model provides a way of thinking has also been found to open up classificatory tool for identifying and separating fresh possibilities for improving health in urban out different layers of knowledge and contexts.125 appropriate to each.119,120 Most of the literature is sparse on detail regarding A number of empirical studies have suggested that exactly how this thinking was applied and its complex adaptive systems approaches have a role merits relative to other potential approaches. to play in supporting practical changes, such as the development of more sophisticated balanced 6.3 Less positive features scorecard indicators of organisational or team success, for example. Potential issues with complex adaptive systems thinking include: it may provide an ‘excuse’ not to Another practical example is a systematic review strive to understand the causes of organisational that found that organisational interventions and social phenomenon, it may be defined so for people with diabetes were more likely to be differently by various authors that only certain successful if they included characteristics of aspects have been applied rather than testing the complex adaptive systems in their design. The entire model. Whilst challenging assumptions, authors concluded that complexity science may it may also include assumptions of its own such provide an effective framework for designing and as the suggestion that some form of ‘natural implementing interventions that lead to improved order’ and alignment will always happen within patient outcomes.121 the systems under investigation. Most of the This approach also has direct implications for available research on leadership and organisational leadership and management styles. Authors development focuses on team dynamics and suggest that command, control and planning interrelationships so the extent to which this are managerial tasks that come to the fore thinking might have broader applicability is when a ‘machine view’ or non complex view of uncertain. organisations is used. However, if organisations Complex adaptive systems theory has been defined are treated as complex adaptive systems the in a number of different ways and there is not focus of managerial activity changes, and sense- necessarily a consensus about the most appropriate making, learning and improvisation become definition for use in healthcare. In fact, some argue more appropriate strategies for performance that the application of this model in health services improvement.122 has not understood the value of the theory fully. 126

Complex adaptive systems 25 The way in which complexity is usually 6.4 Pros and cons interpreted in the healthcare literature misses the whole point of complexity Despite these issues, it appears that complex theory... Complexity provides an adaptive systems thinking has been used to good effect within a number of disciplines including the explanation of patterns and structures physical and environmental sciences, psychology, in certain systems by modelling known management, education and healthcare. In the field outcomes at the global level in terms of of healthcare, complex adaptive systems thinking stimulus-response rules governing the is most commonly used to explore clinical or unilateral, non-intentional behaviour of physical attributes such as theory or nutrition; individual units comprising the system... to consider organisational development from the (but) the healthcare literature typically point of view of personal interactions and to teach regards complexity as a variation on trainee clinicians about clinical and organisational democratic, collaborative, ‘bottom-up’ topics. This model has also been used to explore methods for the management of change in the development of primary care groups. Although systems.127 a number of UK writers have examined the underpinning theory in some detail, empirical Those who are less keen on this way of thinking research from the UK is less evident. suggest complexity therory: To summarise, the most common advantages of –– May be merely a novelty, rather than a detailed complex adaptive systems seen in the empirical way of analysing the world. literature include: 130-135 –– Neglects the ethical and emotional of leadership and management. –– challenges commonly held assumptions –– Conflates description and prescription at the –– focuses on relationships rather than simple cause expense of analysis. and effect models –– Sometimes confuses explanation with –– can be applied in a variety of contexts prediction. –– provides a framework for categorising –– Can be relativist. knowledge and agents –– Advocates self organisation and as such risks –– can help to provide more detailed analyses of exonerating leaders and managers from research evidence accountability and responsibility.128 –– suggests new possibilities or options for change –– provides a more complete picture of forces There have also been critiques of potential affecting change. unrealistic expectations and implementation. As a vehicle for moving away from reductionist There has been growing interest in accounts, complexity theory potentially has much applying complexity theory to health care to say to those interested in research on health systems, both in policy and academic inequalities, spatial diffusion, emerging and research discourses. However, its resurgent infections, and risk.136 application often lacks rigour - authors discuss the properties of complex systems, state that they apply to health care and draw conclusions anchored around the idea of 'whole system change.129

26 THE HEALTH FOUNDATION The most common caveats include:137 Systems theory, organisational –– a lack of empirical application development, social worlds theory, –– lack of comparison with other theories and and complexity theory each has a models –– lack of predictive value practical contribution to make to our –– may be used to justify a lack of intervention understanding of how indicators work as assumes some type of natural evolution will occur. in prompting quality improvements and why they sometimes don’t. Overall, this research scan suggests that a complex adaptive systems approach supports thinking about There may be a need for a clearer definition of this leadership and organisational development in approach and how it applies to healthcare as well as healthcare, not least of which because it may help comparisons with alternative theories so the pros to challenge taken for granted assumptions. Some and cons can be more fully understood. The value suggest it may be best used in combination with of this approach remains relatively unexplored other approaches that offer insights into specific in empirical terms. It might be beneficial for substantive content or which allow further research to explore how the model could 138-146 predictions. be applied in practical terms to specific work Systems theory, organisational development, programmes in order to help build the empirical social worlds theory, and complexity theory evidence base. each has a practical contribution to make to our understanding of how indicators work in prompting quality improvements and why they sometimes don’t.147

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32 THE HEALTH FOUNDATION The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK.

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