Complex adaptive systems approaches in health care-A slow but real emergence?

‘If it is complex it means we don’t really understand it,and the way forward is to break the problem down into its partsto make sense of it’. This thought reflects the way we havebeen taught, and the way we largely practise in clinical care everyday.But are we really functioning on this basis? Or is it the only waywe know how to live? We all experience situations every daywhere the evidence does not really fit our understanding of aproblem – the familiar reductionist approach limits our ability tofully explore new problems and to gain new insight. An increas-ingly persistent question has emerged in relation to what consti-tutes the knowledge we need for effective and efficient clinicalcare, an issue taken up by this new

PurposeThe purpose of this paper is to examine how a complex adaptive systems (CAS) approach can be used to promote the integration of health and social care for the benefit of the user.Design/methodology/approachThis paper is a research review and a conceptual analysis of key issues identified in the growing literature on CAS. An application of the CAS approach to the field of integrated care is presented. The paper identifies crucial issues, notably: bringing together different providers and the place of the user as a co‐producer of care.FindingsThe benefits of the CAS approach to integrated care are distilled. Above all CAS provides managers of health and social care with an alternative mindset. Guiding principles are offered to these managers to facilitate development towards a more integrated system of health and social care. The possibility to benefit from the user's own resources is increased when organizations are viewed from a CAS perspective. CAS promotes emergent ways of working.Practical implicationsThe CAS approach makes possible a significant improvement in relationships between providers and users and managers and providers; a possibility of more productive relationships and better care outcomes, not least in terms of user satisfaction.Originality/valueThe paper shows that CAS literature applied to the health and social care field points the way for managers to rethink the functioning of the field, specifically to go beyond the present dominant but outdated machine model to one which encourages the cooperation of providers and users for better outcomes.

Complexity Leadership Theory: Shifting leadership from the industrial age to the knowledge era

Adaptive Leadership in Parents Caring for their Children Born with Life-Threatening Conditions

PurposeBusiness environments and global transportation system have become more complex than ever due to complexity drivers of industries which create uncertainty and unpredictability to organizations. Like other industries, the maritime business faces different and difficult problems which threaten organizational survival. The ability to cope with those uncertainties, threats and problems shows the resilience ability of organizations that help to survive and prosper. The organizational resilience concept arises as a requirement to deal with problems and uncertainties of business environments which are swiftly changing. This study aims to suggest an organizational framework to show how maritime business organizations as the sea leg of global transportation system can develop resilient organizations via complex adaptive systems (CAS) approach if adequate design features of CAS could be defined and included in organizational properties.Design/methodology/approachA total of 15 CAS features were identified as the enablers of organizational resilience throughout the literature. An interpretive structural modeling (ISM) approach has been conducted to determine the mutual relation between the CAS features which constitute an organizational framework. These CAS features have been categorized by conducting MICMAC analysis.FindingsThis study proposes a framework that identifies CAS features as the enabler of resilient maritime business organizations. The CAS approach offers new managerial toolkit to realize current organizational situations and allows managers to understand that it is difficult to control their system in this dynamic environment where special management practices are required especially in volatile times rather than ordinary times. Also, organizations could not compete as a sole organization but as a web/system of organizations. CAS is more resilient than other systems because resilience is the emergent occurrence of the system formed from nonlinear, dynamic interactions with self-organized agents.Research limitations/implicationsThe research has some limitations, like organizational resilience studies are in the infant stage and further research into this area should be extended. This study uses the CAS approach to develop organizational resilience. Further studies could use different lenses and contemporary subjects in management field which should also be useful while developing resilience in organizations. This study uses ISM and MICMAC analysis where further studies could use quantitative design and methods like formal concept analysis or the decision making trial and evaluation laboratory to determine the relational weighs of CAS features while developing resilient organizations. Future studies may also focus on different maritime stakeholders like IMO or ILO, maritime agencies, freight forwarders or insurance underwriters regarding developing and enhancing resilience of the maritime system.Practical implicationsWorld trade and transportation systems are getting more uncertain and lean on complex relations where maritime transportation is a “vital backbone” of such operations. But becoming more complex structures leads to vulnerable systems and organizations. Most risk management applications are based on predicting the known risks where many of them are not enough to fight with unknowns. Coping with today's problems are difficult for organizations in any industry. But for maritime business stakeholders who work in such a global web of relations, it is much more challenging. So, stakeholders of the system like forwarders, ports or ship chandlers may easily apply those features to develop resilient organizations too. Legal authorities of the system and rule-makers like local Chambers of Shipping, IMO or Classification societies can benefit from this framework and provide supportive settings to develop system-wide resilient organizations.Social implicationsBy understanding environmental uncertainty and complexity better than others, organizations become resilient and cope with significant difficulties which make them more competitive as a substantial strategic advantage. Resilient management offers to break down points at the system and shows them ways to restore quickly while transporting goods while traditional risk assessments are not enough.Originality/valueThe originality of the study lies in two folds; first of all the key and most used features of CAS is linked to developing resilient maritime organizations and by maritime expert opinions, this study tries to determine which of these CAS features are the most effective to trigger other features to develop organizational resilience in the maritime business. And secondly, the concept of organizational resilience and the CAS approach are not analyzed in depth in the context of maritime business.

This project investigates the issue of unwarranted escalation of commitment in the toy retailing business. Unwarranted escalation of commitment refers to situations where decision-makers allocate additional resources to failing courses of action. In addition this project aims to identify several complex adaptive system issues within the toy retailing industry in Australia, proposing that the industry satisfies the underlying assumptions of a complex adaptive system. The project is a part of a larger program initiated by Dr. Drew Wollin in pursuing the dual themes of unwarranted escalation of commitment and complex adaptive systems. The Australian toy retailing industry has, since the entrance of the two category killers World 4 Kids and Toys R Us in 1993, been undergoing some major competitive changes. Their entrance was predicted to boost sales and both were aiming for a market share of 20 per cent by late 1995. However, sales remained flat and the objectives were never achieved. After severe price wars and pushed margins, the two giants lost money every year in the period 1993 to 1998, with individual accumulated losses of approximately AU$ 200 million. This project addresses how the organisations persisted as failing ventures. In particular, did they experience unwarranted escalation of commitment to failing courses of action? While there is a lot of contemporary literature in the area of escalated commitment, there is limited research that examines the phenomenon at an organisational level. The most notable exceptions are the case studies by Ross and Staw (1986, 1993) and Newman and Sabherwal (1996). The former investigated a world fair held in Canada (1986) and a decision to set up a nuclear power plant in the US (1993), while the latter examined organisational escalation of commitment in information systems development. This earlier work indicates that models of organisational unwarranted escalation of commitment have not reached theoretical saturation. The two models available, the non-cyclic model (Ross and Staw, 1993) and the cyclic model (Newman and Sabherwal, 1996), are quite different by nature. However, they agree on the escalation determinants. These are project, psychological, social, organisational (structural), and contextual determinants, which are all (to different extents) addressed in this research. Limited amount of theory has investigated complex adaptive systems in organisational and industrial contexts. This study explores whether the theory of complex adaptive systems may contribute to more fully understand the phenomenon of organisational escalation of commitment. A three-level methodological design is proposed in order to address the relevant issues. The macro-research design is analytic induction. This study is part of ongoing research program and performs one iteration of the analytic induction process. The meso-research design is case study research, whereas the micro-research design employed is historical research, based primarily on secondary evidence. Three significant modifications to existing escalation theory are suggested. First, social determinants were found to be important in all phases of the project. As this is one of few studies investigating unwarranted escalation in competitive environments, it is proposed that game theory aspects be incorporated in the social determinants. Second, organisational determinants were significant in the initial commitment decision processes. Third, contextual determinants were to a greater extent present at all stages. This study argues that the Australian toy retailing industry is a complex adaptive system, and displays behaviour expected from such systems. It is suggested that more research be done aiming to provide explanation of organisational unwarranted escalation in terms of behaviour expected from complex adaptive systems.

While all non-profits struggle to secure and keep funding for their mission-driven organizations, reports show that non-profits led by people of color are at an even greater disadvantage when it comes to securing resources, according to Burton and Barnes. For this reason, many leaders are taking it upon themselves to experiment with different strategies that allow them to diversify the resources available to them, build better networks, and constantly keep the relevance of what their organizations offer at the forefront. Traditionally when we speak about underserved populations and grassroots organizations that serve them grappling with inequity, we tend to use words like "tenacity" and "resilience" to describe how these organizations press on against adversity and manage to succeed in the end. If we consider the concept of access as it relates to the non-profit ecosystem - that collection of organizations and networks that directly or indirectly impacts the systems within it - we can envision a three-part cycle that includes building and sustaining partnerships, access and social capital, and credibility and connections. All three entry points in the cycle are necessary, and all three are able to be enhanced or blocked by the actors within the greater ecosystem. This multidimensional view of the problem required a multidimensional analysis, hence the choice to employ complexity leadership theory (CLT). Uh-Bien and Arena describe CLT as: "...necessarily enmeshed within a bureaucratic superstructure of planning, organizing, and missions. CLT seeks to understand how enabling leaders can interact with the administrative superstructure to both coordinate complex dynamics (i.e. adaptive leadership) and enhance the overall flexibility of the organization. By changing their complexity, Complex Adaptive Systems (CAS) enhance their ability to process data, solve problems, learn and change creatively." Data collected during this narrative study, leveraging CLT as its theoretical framework, was analyzed with the CAS model in mind, searching for patterns in events and circumstances that led to adaptive shifts in practices. The advantage of the CAS model is it allows for specific categories of measurable and replicable activities that each present their own type of strategy for actual impact toward solving the problem. The ways in which various stakeholders' practices and recommendations for improvements were integrated into the overall decision-making processes of the participant organizations were also examined in the context of understanding what the participants - leaders within the education-based non-profit sector - had to say about their experiences launching, funding, and sustaining their organizations. The resulting study provided insights into not only understanding and quantifying the impact of inequitable practices within the philanthropic ecosystem but tangible, practice-focused, strategies for improving the sector's equity by intentionally focusing on the implementation of more collaborative and inclusive practices. Keywords: agency, ecosystem, sustainability, complexity leadership theory, Complex Adaptive Systems, reparations, fee-for-service, social entrepreneurship, liberatory programming, tribal sovereignty, youth-led programming, financial vulnerability, racial wealth gap

The aim of this paper is to discuss the implications of a complex adaptive systems approach to the management of logistics operations. The research is a result of the need for managers of logistics operation to be able to adapt to the ever-changing demands of their environment and customer demands. The identified emphasis of mechanistic assumptions in traditional modeling of logistics is discussed and it is suggested that a change towards adaptive models and tools is needed. This means that the models have to be able to consider more complex behavior such as self-organization and emergent phenomena. A complex adaptive system (CAS) approach is applied by the use of agent-based modeling (ABM). Two cases are provided in which the CAS approach has been applied through ABM simulations. It is concluded the CAS approach implemented by the use of ABM can provide valuable insights for both researchers and practitioners within the field of logistics management.

ObjetivoO ambiente de negócios global gera diferentes problemas que ameaçam a sobrevivência da organização. Como solução relevante, surge o conceito de resiliência organizacional que oferece uma filosofia holística. O conceito de resiliência oferece uma literatura multidisciplinar eclética e é valioso para estudos organizacionais que ajudam a produzir uma grande variedade de soluções, mas há falta de consenso para medir e aplicar resiliência a nível organizacional. Para colmatar esta lacuna, este trabalho oferece a Abordagem Complex Adaptive Systems (CAS) como uma lente para organizações. O objetivo deste estudo é demonstrar que os Sistemas Adaptativos Complexos (CAS) fornecem um conjunto adequado de ferramentas para abordar o conceito de resiliência organizacional, uma vez que tem o potencial de oferecer orientações mais generalizadas.Design/metodologia/abordagemPara atingir este objetivo, esta investigação segue duas fases de revisão sistemática da literatura. Na primeira fase, o objetivo foi procurar em cinco anos (2015–2020) investigar as tendências atuais nos conceitos de resiliência organizacional. Na segunda fase, verifica-se estudos de resiliência organizacional que incluem a abordagem CAS para analisar os procedimentos de alinhamento de dois conceitos.ConclusõesA literatura mostra que o conceito de resiliência organizacional não está ligado a Sistemas Adaptativos Complexos (CAS). Os sistemas adaptativos complexos são mais resistentes através da adaptação e da aprendizagem, pois dependem de interações locais que moldam e co-evoluem juntamente com o seu ambiente dinâmico que ajuda a emergir como auto-organização num futuro imprevisível. Para alcançar a resiliência organizacional, a lente CAS propõe um quadro generalizável aplicável aos estudos organizacionais.OriginalidadeA originalidade do estudo consiste em propor a obtenção de resiliência organizacional através de Sistemas Adaptativos Complexos (CAS) e oferece um quadro conceptual para alcançar a resiliência organizacional.Palavras-chaveResiliência organizacional, Abordagem de sistemas adaptativos complexos (CAS), Revisão sistemática de literatura, Modelo conceptualTipo de manuscritoPapel conceitual

The emergence and use of complex adaptive systems remedied the need for a new alternative by resorting to existing paradigms. Both the health care system and nursing can be regarded as complex adaptive systems by applying a visual model that should be explored to empower the complexity of the science of nursing and health care. Viewed from this perspective, a nurse is a complex adaptive system, one that is dynamic and interacts, but is also an agent of a complex adaptive system in a nursing unit, which in turn is a complex adaptive system in a health organization. Today, nursing professionals seek to be current in terms of training and skilled in a variety of special fields, ranging from neonatal nursing to geriatric care, in order to do their job and to envision a working environment from the perspective of a complex system. Consequently, through complex systems based on shared knowledge among various professional and teamwork, organization of the health-care system is able to enjoy the support of the client-user-professional chain.

Concepts from complexity science are familiar experiences for those working in primary health care. We work with people, each one different from every other. We have the privilege of knowing our patients over long periods of time, and this helps us understand them better. We are not surprised by how differently patients respond to a particular treatment. We witness the influence of family and community on our patient’s experience of health and illness and the opportunities and constraints of health care provision within our organizational and policy context.1 As clinicians, we may work within organizations comprised of many individuals and experience the effect of the quality of communication on the organization.2 When we visit a different primary care practice, even though they may have similar objectives and resources and work in a similar way to our own, the difference in the character of the practice is often striking.3 Complexity sciences seek to understand complex systems. People and primary care organizations are examples of complex systems. They have emergent properties that are not explainable using linear models of interaction or causality. Seemingly similar complex systems such as people or organizations become diverse as small differences become amplified through interaction and feedback. The history of a complex system influences its current properties and these constantly evolve. The system is engaged within its context, changing it and being changed.4 Despite the apparent fit between complexity sciences and primary health care, what complexity sciences have to offer primary care research is still an open question. As a novel approach to research, complexity science challenges us to think clearly about the nature of reality and how we come to understand it, questions of ontology and epistemology, and challenges our understanding of causation and how we detect it. Where we are stuck on a particular problem, complexity sciences may offer an innovative way of thinking about it without necessarily needing new research methods. Studying interaction and its dynamics, and studying emergence may be of particular importance for primary care research and require learning or developing new research methods. Arguably the most robust current research in complexity sciences looks inside complex inanimate or cellular systems. Examples include energy networks, computer networks, moving fluids, and cellular enzyme systems. Large volume longitudinal data is collected and analyzed using data mining techniques. Computer simulation of the system can be compared with real life. Mathematics succinctly describes the structure and dynamics of the system. These research approaches require data that capture interaction. We have data about information exchange within our primary care organizations that can be analyzed in terms of network structure and dynamics. Similarly, patient interaction with health care may be explored through case by case longitudinal analysis of our patient data. However, our patients interact with their social and environmental context, and this influences their health.5 This dynamic interaction is poorly documented within available health care data. Linkage of large data sets from social surveys, census, and health care may provide future opportunities for analysis of this dynamic interaction; however, smaller scale mixed-method longitudinal research is likely to be more productive in the short term. Although medical science can claim many successes, there are health problems, for example low back pain and depression, where it can be argued traditional research approaches seem to be stuck. A complexity sciences approach may consider such health problems emergent phenomenon arising from the interaction of many different factors, biological, psychological, technological, social, and environmental. Emergence cannot be tracked back to a particular cause. Similarly, interactions between patients and physicians have emergent properties that are not determined by the patient or the doctor, but develop through their interchange. The function of a primary care practice emerges from the interaction of those who work there, the patients and context. Understanding emergence is a challenge for complexity science, not just for primary care, and is receiving attention from many research disciplines. NAPCRG will continue to serve as a forum for complexity science researchers to learn from one another and to create new, practical insights that will improve the design and delivery of primary health care.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Complex adaptive systems are a special kind of system with emergent properties and adaptive capacity in response to external environmental conditions. In this chapter, I investigate the proposition that international environmental law, as a set of multilateral environmental agreements, exhibits the characteristics of a complex adaptive system. This proposition is premised on the scientific understanding that the subject matter displays properties of a complex adaptive system. If so, the legal system may benefit from the insights gained and from being modeled in ways more appropriately aligned with the functioning of the Earth system itself. I provide as context a scientific explanation of the Earth system as a complex adaptive system. I then consider if international environmental law can be understood as a system, which is complex and adaptive. From this exploratory review, I found evidence suggesting that international environmental law is a system with interactive elements. I also found indications of self-organization and emergence, suggesting that international environmental law is a complex system. However, it is still questionable whether the legal system has been autonomously adaptive to and co-evolving with global environmental and geopolitical change in ways that lead to net environmental improvement.

This paper presents results from a research project on the behavior of complex systems after they experience disruptive events that impact their performance. As systems become more complex, the probability increases that they will exhibit emergent behavior that could lead to system failures or widespread and prolonged service interruptions. A complex adaptive system (CAS) approach is used to conceptualize a complex network system that has been impacted by disruptions and perturbations. A combination of network analysis and agent‐based modeling is used to measure the performance of the system as it responds to disruptive events and restoration efforts. This system‐level behavior is an emergent property of the complex network and represents system resilience. Various resilience measures are used to quantify system resilience and assess the effectiveness of strategies system owners employ to restore the system. We illustrate our techniques by characterizing a critical infrastructure system network as a CAS, and applying an agent‐based simulation with an adaptive algorithm.

This paper uses the experiences of a programme designed to bring about change in performance of public health nurses (health visitors and school nurses) in an inner city primary care trust, to explore the issues of professional and organizational change in health care organizations. The United Kingdom government has given increasing emphasis to programmes of modernization within the National Health Service. A central facet of this policy shift has been an expectation of behaviour and practice change by health care professionals. Change was brought about through use of a Complex Adaptive Systems approach. This enabled change to be seen as an inclusive, evolving and unpredictable process rather one which is linear and mechanistic. The paper examines in detail how the use of concepts and metaphors associated with Complex Adaptive Systems influenced the development of the programme, its implementation and outcomes. The programme resulted in extensive change in professional behaviour, service delivery and transformational change in the organizational structures and processes of the employing organization. This gave greater opportunities for experimentation and innovation, leading to new developments in service delivery, but also meant higher levels of uncertainty, responsibility, decision-making and risk management for practitioners. Using a Complex Adaptive Systems approach was helpful for developing alternative views of change and for understanding why and how some aspects of change were more successful than others. Its use encouraged the confrontation of some long-standing assumptions about change and service delivery patterns in the National Health Service, and the process exposed challenging tensions within the Service. The consequent destabilising of organizational and professional norms resulted in considerable emotional impacts for practitioners, an area which was found to be underplayed within the Complex Adaptive Systems literature. A Complex Adaptive Systems approach can support change, in particular a recognition and understanding of the emergence of unexpected structures, patterns and processes. The approach can support nurses to change their behaviour and innovate, but requires high levels of accountability, individual and professional creativity.