A systems science perspective on the capacity for change in public hospitals

Abstract

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the “3 + 3 Decision Framework” proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Implementation of a whole of hospital sepsis clinical pathway in a cancer hospital: impact on sepsis management, outcomes and costs

“… 35 Senior medical staff support is another critical factor that has been shown to impact on efforts to change public hospital systems. 36 …”

Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

“…Agents and the whole system alter their behaviors and interactions according to the characteristics of other agents and the impact of external circumstances, in other words, they adapt to new conditions [ 25 , 39 , 40 ]. The interactions between multiple agents, feedback mechanisms, and flow of information are key learning sources and drivers of adaptation which is an essential phenomenon in CAS [ 27 ].…”

“…One of the pivotal characteristics that define a CAS is emergence [ 36 ]. The core concept of this feature is that the whole behavior of the system is probably greater and more complex than the sum of individual behaviors [ 25 , 40 ]. The interplay of elements results in behavior in the whole system, which cannot be easily observed and predicted [ 27 , 42 , 43 ].…”

“…Generally, classic approaches to solving health problems are inadequate as they often tend to ignore the subtle inherent complexities of the problem in favor of its easily visible features [ 24 ]. Therefore, in the face of such baffling complexities, achieving public health goal would definitely require going beyond overly simplistic notions [ 25 ].…”

“…Recently complexity science approach to health, settings, and organizations has emerged as a promising approach that can provide a more thorough understanding of complex health issues [ 27 – 32 ]. Similarly, applying the Complex Adaptive Systems (CAS) theory, a derivative of complexity science, to understand, explore, scale-up, evaluate and research in health systems has become popular among researchers in recent years [ 25 , 33 – 36 ].…”