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Refereed Paper Complex Adaptive Systems (CAS): an Overview of Key Elements, Characteristics and Application to Management Theory

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Refereed Paper Complex Adaptive Systems (CAS): an Overview of Key Elements, Characteristics and Application to Management Theory Informatics in Primary Care 2011;19:33–7 # 2011 PHCSG, British Computer Society Refereed paper Complex adaptive systems (CAS): an overview of key elements, characteristics and application to management theory Beverley Ellis MA PhD FHEA MBCS CITP Subject Lead/Principal Lecturer in Health Informatics, School of Health, University of Central Lancashire, Preston, UK Stuart Ian Herbert BA(Hons) FBCS CITP Director and Independent Health Informatician, SI Herbert & Associates Ltd ABSTRACT Objective To identify key elements and character- tractual requirements. Informatics was acknow- istics of complex adaptive systems (CAS) relevant ledged as a mechanism to link electronic health to implementing clinical governance, drawing on record outputs, quality improvement and resources. lessons from quality improvement programmes Investment in informatics was identified as a devel- and the use of informatics in primary care. opment priority in order to embed clinical govern- Method The research strategy includes a literature ance principles in practice. review to develop theoretical models of clinical Conclusions Complex adaptive system theory governance of quality improvement in primary care usefully describes evolutionary change processes, organisations (PCOs) and a survey of PCOs. providing insight into how the origins of quality Results Complex adaptive system theories are a assurance were predicated on rational reductionism valuable tool to help make sense of natural and linearity. New forms of governance do not phenomena, which include human responses to neutralise previous models, but add further dimen- problem solving within the sampled PCOs. The sions to them. Clinical governance models have research commenced with a survey; 76% (n16) of moved from deterministic and ‘objective’ factors respondents preferred to support the implemen- to incorporate cultural aspects with feedback about tation of clinical governance initiatives guided by quality enabled by informatics. The socio-technical outputs from general practice electronic health lessons highlighted should inform healthcare man- records. There was considerable variation in the agement. way in which consultation data was captured, recorded and organised. Incentivised information Keywords: clinical governance, complex adaptive sharing led to consensus on coding policies and systems, informatics, primary care, quality assur- models of data recording ahead of national con- ance, socio-technical Introduction There are various governance models that guide current Complex adaptive systems (CAS) is a framework quality improvement programmes used by health that assists thinking about the nature of quality im- services.1,2 This paper summarises a review of com- provement programmes in primary care organisations plex adaptive system explanations of problems in (PCOs). The review includes practical frameworks, networked organisations. It draws on examples from designed to ensure delivery of health service quality primary care informatics, which include workarounds improvements enabled by developments in primary and use of financial incentives to overcome obstacles. care informatics. The findings should improve our 34 B Ellis and SI Herbert understanding of management approaches and the between layers of systems (control loops and feed- control of new organisational forms. back); principles that guide a variety of systems to achieve their purpose by ‘the return of information to form a closed loop’.3 Method The ideas of feedback, non-linear causation and self-regulation mark the move towards a collaborative, network-based understanding of governance. We carried out a literature review and developed a In 1984, the Santa Fe Institute in New Mexico theoretical framework that facilitates interpretation of studied the behaviour of CAS. A state between stable the case studies upon which this series of papers is and unstable behaviour was discovered, attributable based.2 Approaches that suit CAS are identified and to interactions between agents and elements within examined. Complexity thinking introduces new and a system. Activity was simulated using simple rules different metaphors and provides a language for under- applied by each of a network of moving digital agents 4–6 standing the nature of responses to quality improve- (boids). The idea of ‘simple rules’ has subsequently ment programmes in PCOs. The review discusses been applied by organisational theorists as a way of concepts dealing with relations, interdependencies, interpreting the complex behaviour found in organ- governance and managerial responses to quality im- isational communities.7–13 provement programmes in PCOs. Key elements, features and management principles that characterise CAS are summarised in Table 1. Complex interactions and interdependencies emerge within CAS which cannot be understood or predicted Results simply by studying individual elements of the system; novel system behaviour emerges. Humans possess the Complex adaptive systems capacity to reflect, which may result in alternative paths of action to those prescribed within simple rules. Complex adaptive system ideas are associated with The interacting component units within CAS result in developments in second-order thinking. The second- a system-wide governance, because influence is exer- order view of systems describes recursive interactions cised both by the system on the units and by the units Table 1 CAS elements and management principles Core CAS elements Features Management principles Multiple agents with Informal, collaborative networks of Respect democratic principles that schemata individuals that partner and lead to mutual adjustment; jointly contribute to solution making steer courses of action Connectivity and interdependence between agents Degrees of connectivity Self-organising networks Holistic patterns formed through Adjust the fitness landscape: offer human interactions incentives, and longer term rewards Causation by setting priorities. Apply simple Feedback design principles because they turn into rules; ensure that lines of communication flow across network, so authority and legitimacy become vested in the process as a whole, not on the perspective of one Coevolution Innovative pathways of governance Appreciate and monitor the emerge – a variety of what is known implications of feedback, non-linear as ‘emergent behaviour’ in CAS and mutual causation System adaptation Networks represent additions to Respect individuals and their hierarchies organisations that exist in an ecosystem – avoid major change CAS: an overview of key elements, characteristics and application to management theory 35 on the system – termed ‘mutual causation’. Quality European Foundation of Quality assurance is introduced next, a formal framework Management Excellence Model within which quality health care is currently delivered within PCOs. The government explicitly commended the EFQM Excellence Model as a management framework for clinical governance,19–22 as a model that provides: Quality assurance an enhanced focus on aspects of excellence that are becoming increasingly important such as the manage- Quality assurance is associated with the application of ment of partnerships and knowledge ... explicit focus on scientific methods to management and 20th century the value to users of the ‘plan, do, check, act’ cycle; a need industrial production. Its aim is to increase the pro- to relate everything that is done, and the measurements portion of products without faults. Quality improve- taken, to what policy and strategy is seeking to achieve. ment in health care is sometimes bedevilled by the (www.efqm.org) difficulty of defining universal measures of a ‘best’ (or The EFQM Excellence Model reflects a logic known as sometimes even ‘good’) outcome for patients, bearing RADAR which consists of the elements: results, ap- in mind the very variable case mix receiving health proach, deployment, assessment and review. Advo- care and the considerable uncertainty about cause and cates of the EFQM Excellence Model suggest it has effect in some individual (and occasionally general) an inherent capacity to reflect the processes of quality cases. This makes it particularly suited to a CAS service provision. The EFQM Excellence Model posits approach, and both outcome-oriented and process- that five sub-criteria need to be addressed: oriented measures need to be considered to effectively evaluate performance from a user/service satisfaction 1 processes are systematically designed and managed perspective. There is a consensus that the key charac- 2 processes are improved as needed, using inno- teristics of a healthcare quality assurance framework14 vation in order to fully satisfy, and generate increas- include: ing value, for customers and other stakeholders 3 products and services are designed and developed . Leadership Senior management should actively based on customer needs and expectations participate in quality assurance programmes, as 4 products and services are produced, delivered and partners rather than pharaohs. serviced . Organisational characteristics The organisation 5 customer relationships are managed and enhanced. should provide moral and material support. Characteristics of the health professionals They The model is based on nine criteria. Five of these are should be willing to take part in the programme and ‘enablers’ and four are ‘results’. The ‘enabler’ criteria be responsive to findings. cover what an organisation does. The ‘results’ criteria . Technical quality of monitoring system
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