Using complexity theory to analyse the organisational response to resurgent tuberculosis across London

Application of complexity theory in health and social care research: a scoping review

BACKGROUND

Complexity theory has been chosen by many authors as a suitable lens through which to examine health and social care. Despite its potential value, many empirical investigations apply the theory in a tokenistic manner without engaging with its underlying concepts and underpinnings.

OBJECTIVES

The aim of this scoping review is to synthesise the literature on empirical studies that have centred on the application of complexity theory to understand health and social care provision.

METHODS

This scoping review considered primary research using complexity theory-informed approaches, published in English between 2012 and 2021. Cochrane Database of Systematic Reviews, MEDLINE, CINAHL, EMBASE, Web of Science, PSYCHINFO, the NHS Economic Evaluation Database, and the Health Economic Evaluations Database were searched. In addition, a manual search of the reference lists of relevant articles was conducted. Data extraction was conducted using Covidence software and a data extraction form was created to produce a descriptive summary of the results, addressing the objectives and research question. The review used the revised Arksey and O'Malley framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR).

RESULTS

2021 studies were initially identified with a total of 61 articles included for extraction. Complexity theory in health and social care research is poorly defined and described and was most commonly applied as a theoretical and analytical framework. The full breadth of the health and social care continuum was not represented in the identified articles, with the majority being healthcare focused.

DISCUSSION

Complexity theory is being increasingly embraced in health and care research. The heterogeneity of the literature regarding the application of complexity theory made synthesis challenging. However, this scoping review has synthesised the most recent evidence and contributes to translational systems research by providing guidance for future studies.

CONCLUSION

The study of complex health and care systems necessitates methods of interpreting dynamic prcesses which requires qualitative and longitudinal studies with abductive reasoning. The authors provide guidance on conducting complexity-informed primary research that seeks to promote rigor and transparency in the area.

REGISTRATION

The scoping review protocol was registered at Open Science Framework, and the review protocol was published at BMJ Open (https://bit.ly/3Ex1Inu).

A systematic assessment on COVID-19 preparedness and transition strategy in Bangladesh

RATIONALE, AIMS, AND OBJECTIVES

The COVID-19 pandemic of 2020 has overpowered the most advanced health systems worldwide with thousands of daily deaths. The current study conducted a situation analysis on the pandemic preparedness of Bangladesh and provided recommendations on the transition to the new reality and gradual restoration of normalcy.

METHOD

A complex adaptive system (CAS) framework was theorized based on four structural dimensions obtained from the crisis and complexity theory to help evaluate the health system of Bangladesh. Data sourced from published reports from the government, non-governmental organizations, and mainstream media up to June 15, 2020 were used to conduct a qualitative analysis and visualize the spatial distribution of countrywide COVID-19 cases.

RESULTS

The findings suggested that Bangladesh severely lacked the preparedness to tackle the spread of COVID-19 with both short- and long-term implications for health, the economy, and good governance. Absence of planning and coordination, disproportionate resource allocations, challenged infrastructure, adherence to bureaucratic delay, lack of synchronized risk communication, failing leadership of concerned authorities, and incoherent decision-making have led to a precarious situation that will have dire ramifications causing many uncertainties in the coming days.

CONCLUSIONS

Implementation of response protocols addressing the needs of the community and the stakeholders from the central level is urgently needed. The development of mechanisms for dynamic decision-making based on regular feedback and long-term planning for a smooth transition between the new reality and normalcy should also be urgently addressed in Bangladesh.

The stipulation-stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation

Many representations of the movement of healthcare knowledge through society exist, and multiple models for the translation of evidence into policy and practice have been articulated. Most are linear or cyclical and very few come close to reflecting the dense and intricate relationships, systems and politics of organizations and the processes required to enact sustainable improvements. We illustrate how using complexity and network concepts can better inform knowledge translation (KT) and argue that changing the way we think and talk about KT could enhance the creation and movement of knowledge throughout those systems needing to develop and utilise it. From our theoretical refinement, we propose that KT is a complex network composed of five interdependent sub-networks, or clusters, of key processes (problem identification [PI], knowledge creation [KC], knowledge synthesis [KS], implementation [I], and evaluation [E]) that interact dynamically in different ways at different times across one or more sectors (community; health; government; education; research for example). We call this the KT Complexity Network, defined as a network that optimises the effective, appropriate and timely creation and movement of knowledge to those who need it in order to improve what they do. Activation within and throughout any one of these processes and systems depends upon the agents promoting the change, successfully working across and between multiple systems and clusters. The case is presented for moving to a way of thinking about KT using complexity and network concepts. This extends the thinking that is developing around integrated KT approaches. There are a number of policy and practice implications that need to be considered in light of this shift in thinking.

The three paradoxes of patient flow: an explanatory case study

BACKGROUND

Health systems in many jurisdictions struggle to reduce Emergency Department congestion and improve patient flow across the continuum of care. Flow is often described as a systemic issue requiring a "system approach"; however, the implications of this idea remain poorly understood. Focusing on a Canadian regional health system whose flow problems have been particularly intractable, this study sought to determine what system-level flaws impede healthcare organizations from improving flow.

METHODS

This study drew primarily on qualitative data from in-depth interviews with 62 senior, middle and departmental managers representing the Region, its programs and sites; quantitative analysis of key flow indicators (1999-2012) and review of ~700 documents furnished important context. Examination of the interview data revealed that the most striking feature of the dataset was contradiction; accordingly, a technique of dialectical analysis was developed to examine observed contradictions at successively deeper levels.

RESULTS

Analysis uncovered three paradoxes: "Many Small Successes and One Big Failure" (initiatives improve parts of the system but fail to fix underlying system constraints); "Your Innovation Is My Aggravation" (local innovation clashes with regional integration); and most critically, "Your Order Is My Chaos" (rules that improve service organization for my patients create obstacles for yours). This last emerges when some entities (sites/hospitals) define their patients in terms of their location in the system, while others (regional programs) define them in terms of their needs/characteristics. As accountability for improving flow was distributed among groups that thus variously defined their patients, local efforts achieved little for the overall system, and often clashed with each other. These paradoxes are indicative of a fundamental antagonism between the system's parts and the whole.

CONCLUSION

An accretion of flow initiatives in all parts of the system will never add up to a system approach, and may indeed perpetuate the paradoxes. What is needed is a coherent strategy of defining patient populations by needs, analyzing their entire trajectories of care, and developing consistent processes to better meet those needs.

Using the structure of social networks to map inter-agency relationships in public health services

This article investigates network governance in the context of health and wellbeing services in England, focussing on relationships between managers in a range of services. There are three aims, namely to investigate, (i) the configurations of networks, (ii) the stability of network relationships over time and, (iii) the balance between formal and informal ties that underpin inter-agency relationships. Latent position cluster network models were used to characterise relationships. Managers were asked two questions, both designed to characterise informal relationships. The resulting networks differed substantially from one another in membership. Managers described networks of relationships that spanned organisational boundaries, and that changed substantially over time. The findings suggest that inter-agency co-ordination depends more on informal than on formal relationships.

Application of simplified Complexity Theory concepts for healthcare social systems to explain the implementation of evidence into practice

AIM

To examine the application of core concepts from Complexity Theory to explain the findings from a process evaluation undertaken in a trial evaluating implementation strategies for recommendations about reducing surgical fasting times.

BACKGROUND

The proliferation of evidence-based guidance requires a greater focus on its implementation. Theory is required to explain the complex processes across the multiple healthcare organizational levels. This social healthcare context involves the interaction between professionals, patients and the organizational systems in care delivery. Complexity Theory may provide an explanatory framework to explain the complexities inherent in implementation in social healthcare contexts.

DESIGN

A secondary thematic analysis of qualitative process evaluation data informed by Complexity Theory.

METHOD

Seminal texts applying Complexity Theory to the social context were annotated, key concepts extracted and core Complexity Theory concepts identified. These core concepts were applied as a theoretical lens to provide an explanation of themes from a process evaluation of a trial evaluating the implementation of strategies to reduce surgical fasting times. Sampled substantive texts provided a representative spread of theoretical development and application of Complexity Theory from late 1990's-2013 in social science, healthcare, management and philosophy.

FINDINGS

Five Complexity Theory core concepts extracted were 'self-organization', 'interaction', 'emergence', 'system history' and 'temporality'. Application of these concepts suggests routine surgical fasting practice is habituated in the social healthcare system and therefore it cannot easily be reversed. A reduction to fasting times requires an incentivised new approach to emerge in the surgical system's priority of completing the operating list.

CONCLUSION

The application of Complexity Theory provides a useful explanation for resistance to change fasting practice. Its utility in implementation research warrants further attention and evaluation.

Taxonomy for complexity theory in the context of maternity care

BACKGROUND

The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking.

OBJECTIVE

This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care.

METHOD

A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy.

FINDINGS

The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them.

Commentary on text of interview with Professor Lord Ara Darzi: 'Desirable? Yes; but is it achievable?'

This personal commentary explores some issues that arise in the text of the interview with Lord Darzi published in LJPC 6.6, from a point of view of an interest in health policy and change in healthcare organisations. It suggests that the vision is desirable but that there are four major questions about ready implementation that the field needs to consider: 1 Can primary care development and investment be protected in a cold financial climate? 2 Does the current marketisation of health care erode integration? 3 Does the health and social care system in London behave like a real system? 4 Is there really a cultural shift towards empowerment and organisational learning?

An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge

Background

Hospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety.

Aim

To identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition.

Setting

The study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways.

Design

The study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors.

Findings

The study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge.

Conclusions

The study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Applying complexity theory: a review to inform evaluation design

Complexity theory has increasingly been discussed and applied within evaluation literature over the past decade. This article reviews the discussion and use of complexity theory within academic journal literature. The aim is to identify the issues to be considered when applying complexity theory to evaluation. Reviewing 46 articles, two groups of themes are identified. The first group considers implications of applying complexity theory concepts for defining evaluation purpose, scope and units of analysis. The second group of themes consider methodology and method. Results provide a starting point for a configuration of an evaluation approach consistent with complexity theory, whilst also identifying a number of design considerations to be resolved within evaluation planning.

Organisational innovation and control practices: the case of public-private mix in tuberculosis control in India

Partnerships between public and private healthcare providers are often seen as an important way to improve health care in resource-constrained settings. Despite the reconfirmed policy support for including private providers into public tuberculosis control in India, the public-private mix (PPM) activities continue to face apprehension at local implementation sites. This article investigates the causes for those difficulties by examining PPM initiatives as cases of organisational innovation. It examines findings from semi-structured interviews, observations and document analyses in India around three different PPM models and the attempts of innovating and scaling up. The results reveal that in PPM initiatives underlying problem definitions and different control practices, including supervision, standardisation and culture, continue to clash and ultimately hinder the scaling up of PPM. Successful PPM initiatives require organisational control practices which are rooted in different professions to be bridged. This entails difficult balancing acts between innovation and control. The innovators handle those differently, based on their own ideas of the problem that PPM should address and their own control practices. We offer new perspectives on why collaboration is so difficult and show a possible way to mitigate the established apprehensions between professions in order to make organisational innovations, such as PPM, sustainable and scalable.