2021
DOI: 10.1136/bmjgh-2021-005582
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Performance management in complex adaptive systems: a conceptual framework for health systems

Abstract: Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and d… Show more

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Cited by 18 publications
(17 citation statements)
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References 54 publications
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“…This is a novel output in the research field because few studies have examined and contradicted the assumption that regulation and resilience are intractable opposites [ 6 – 9 ]. A regulatory and supervisory system that aims at regulating processes, through checking that hospitals are adequately undertaking quality improvement, can be considered both a better fit for a complex system and should also build resilience (and responsiveness to local conditions) through being more enabling of adaptations to local risks [ 6 , 61 ]. As such, the performance-based regime investigated in our study, has great potential in being flexibly applied into hospital management and quality improvement processes.…”
Section: Discussionmentioning
confidence: 99%
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“…This is a novel output in the research field because few studies have examined and contradicted the assumption that regulation and resilience are intractable opposites [ 6 – 9 ]. A regulatory and supervisory system that aims at regulating processes, through checking that hospitals are adequately undertaking quality improvement, can be considered both a better fit for a complex system and should also build resilience (and responsiveness to local conditions) through being more enabling of adaptations to local risks [ 6 , 61 ]. As such, the performance-based regime investigated in our study, has great potential in being flexibly applied into hospital management and quality improvement processes.…”
Section: Discussionmentioning
confidence: 99%
“…On the other hand, autonomy and freedom to tailor improvement efforts require competence, additional resources, and systems to support hospitals and hospital managers, and responsible application by the regulatees [ 39 , 40 , 69 , 70 ]. System’s “software”, including organizational culture, adequate management, and leadership, has shown to be a crucial determinant of quality improvement performance [ 61 , 71 ]. For instance, micro-level noncompliance to implementation may link with a lack of management competences [ 72 ].…”
Section: Discussionmentioning
confidence: 99%
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“… 17 Enabling approaches are guided by logics of improvement and learning; can create conditions for adaptive and iterative cycles of error, reflection, sensemaking and corrective action; and conceive of performance as emergent processes, influenced by managers and workers’ agency, motives, means and opportunities. 18 19 …”
Section: Pmm Systemsmentioning
confidence: 99%
“…Directive systems tend to be guided by a logic of consequences, are prevalent in systems that favour audit cultures,16 are designed with a view towards accountability and follow the utility-maximising assumptions of Homo economicus in agency theory 17 . Enabling approaches are guided by logics of improvement and learning; can create conditions for adaptive and iterative cycles of error, reflection, sensemaking and corrective action; and conceive of performance as emergent processes, influenced by managers and workers’ agency, motives, means and opportunities 18 19…”
Section: Pmm Systemsmentioning
confidence: 99%