Selecting a change and evaluating its impact on the performance of a complex adaptive health care delivery system.

Global demographic shifts of increased life expectancy are a success of our times, yet for many, are accompanied by higher multi-morbidity and patient complexity (1). Research on older people with complex healthcare needs has evolved to focus not only on the ‘health’ domain but also on the interrelated ‘complex social’ care needs. This field remains underserved, with no agreed definition of ‘complex patients’ in the literature (2). The absence of a consensus definition and concept clarification presents a challenge for integrated care systems when developing policy and practice. Older populations with complex care needs often require high levels of support and resourcing, yet many encounter multiple challenges in accessing this support (3) and experience a poorer quality of life. Effective inclusive intervention approaches for this group are imperative, however, should also be outcome-focused and provide a support structure for the staff tasked with providing support. Who is this for? Are you a healthcare or social care practitioner, an operational manager, a social worker, nurse, policy-maker, who has experience or an interest in supporting older people with complex health and social care needs? Or are you a researcher, or academic with an interest in this topic or more broadly in developing policy, procedure or protocols? Aims and Objectives of the Networking: The overall aim of this networking session is to explore the feasibility of developing a research and policy network on how best to support older people with complex health and social care needs. The objectives are to explore and share: (i) interventions that work best for older people with complex health and social care needs; (ii) the impact of older people with complex health and social care needs on integrated care systems, (iii) the feasibility of agreeing a definition of complex health and social care needs; (iv) the feasibility of developing guidelines and policies that support an integrated approach to supporting older people who present with complex needs. Patient and Public Involvement (PPI) and co-design The voice of older people with complex health and social care needs are hard to reach for both research and policy. Therefore, we are particularly interested in exploring novel approaches to meaningfully engaging with this population. A short presentation will be given highlighting the multi-dimensional nature of the topic along with a number of case examples to focus the collaborative discussion. Facilitators: The networking will be led by Dr Austin Warters and co-facilitated by Dr Aurelia Ciblis. References (1)Nicolaus S, Crelier B, Donzé JD, Aubert CE. Definition of patient complexity in adults: A narrative review. Journal of Multimorbidity and Comorbidity. 2022 Feb 17;12. Available from: doi:10.1177/26335565221081288 (2)Kaneko H, Hanamoto A, Yamamoto-Kataoka S, Kataoka Y, Aoki T, Shirai K, Iso H. Evaluation of Complexity Measurement Tools for Correlations with Health-Related Outcomes, Health Care Costs and Impacts on Healthcare Providers: A Scoping Review. International Journal of Environmental Research and Public Health. 2022 Dec 1;19(23):16113. Available from: http://dx.doi.org/10.3390/ijerph192316113 (3)NICE Guideline NG216. Social work with adults experiencing complex needs. 2022 May 26. Available from: www.nice.org.uk/guidance/ng216

Leading Complex Health Care Delivery Systems

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.

Complex adaptive systems (CAS) have been identified as being hard to comprehend, composed of multiple interacting components acting interdependently with overlapping functions aimed at adapting to external/environmental forces. The current theoretical model utilized the natural functions of teams, viewing teams as a complex adaptive system, to develop the structure of the theory of complex adaptive team systems (CATS). The CATS model was formulated around the components of complexity theory (interactions, nonlinearity, interdependency, heterogeneity, complex systems, emergence, self-organizing, and adaptability) to show its utility across multiple domains (the role of leadership, organizational learning, organizational change, collective cognitive structures, innovation, cross-business-unit collaborations). In theorizing the CATS model, a new level of analysis was implemented, the interactions between agents as a move toward emergence in complex systems. The CATS model ultimately provides a model for organizations/institutions to drive knowledge creation and innovation while operating in today's complexity.

Complex adaptive systems (CAS), to reiterate, are systems composed of many individual parts or agents in which patterns can emerges as a result of agents deploying "simple rules" from the "bottom-up" without external control—CAS are "self-organizing" systems. "Simple rules" in health care would include seeking to optimize both patient well-being and the functioning of professionals. If elements of a CAS system are altered, the system adapts or reacts. The behaviour of a complex adaptive system can be inherently unpredictable and non-linear as elements of the system, the internal (eg, professionals and managers) and external agents (eg, patients, families, and society), have multiple perturbations, changes, and interdependencies. Despite the flurry of interest in complex systems and non-linear dynamics in recent decades, application of knowledge and innovation about complexity and adaptation in systems for health care has been slow. Critics typically state that there is no "evidence" that applying CAS and complexity science is needed or "works" in the real world of health care systems.1 It is almost a decade since the issues of practicability were first raised in this Forum in 2009.2 Has progress been made? A PubMed scan (Figure 1) provides some comfort in the growth of applications of CAS thinking in health research. In this Forum, Wietmarschen, Wortelboer, and van der Greef3 provide a highly accessible vision for the future of complex adaptive systems and why they are needed. They re-articulate why a shift is needed from static silos of diagnoses and linear structures toward a more integrated biopsychosocial way of thinking about health, using systems thinking approaches. Moreover, in their far-sighted appraisal of Western lifestyle problems of obesity and sedentary behaviours, they demonstrate practical modelling techniques integrating molecular with cognitive and psychological metrics, and variables from different layers of human functioning. A systems dynamics software tool called Method to Analyse Relations between Variables using Enriched Loops was used to create the model during the group sessions. The resulting model contained various positive and negative feedback loops connecting multiple health domains, indicating non-linear mechanisms affecting processes that cross multiple health domains. These techniques have been applied to the analyses of individual trajectories in a clinical approach to obesity in Vogellanden-Centre for Rehabilitation, Zwolle, the Netherlands. System dynamics modelling (SD), is an interdisciplinary modelling method used for representing and understanding the behaviour of complex systems. An SD model consists of a series of stocks, which represent the total people receiving a type of service at a given time, interconnected through flows, which represent the movement of people from one stock to another over time. Participatory approaches align stakeholder understanding of the underlying causes of a problem and can achieve consensus for action. Advances in software are allowing the participatory model building approach to be extended to more sophisticated multimethod modelling that provides policy makers with more powerful tools to support the design of targeted, effective, and equitable policy responses for complex health problems.4 Cepoiu-Martin and Bischak5 utilized a system dynamics model of the Alberta Continuing Care System (ACCS), Canada, using stylized data to assist service planning. They explored policies of introducing staff/resident benchmarks in both supportive living and long-term care (LTC) in the background of predicted increases in the population of people with dementia and the provision of staffing benchmarks, The ACCS model developed, by going beyond linear cause-effect considerations, and allowed the exploration of the entire network of causal relationships between various components of the system. It provided evidence of applicability of SD simulation to analysis of the impact of adopting benchmarks related to the staff/resident ratios in the continuing care system in Alberta. The model provides a basis for future evaluations of interventions in the workforce development area, capturing all feedbacks that modify balance between staff supply and demand in the age care sector. The following three papers highlight practical applications at the clinical coal-face, albeit all are early stage studies. Bandini et al6 have successfully piloted a clinical tool for episode complexity in inpatient care on internal medical wards. Episode complexity represents the need for greater time and effort (compared with other patients and episodes) with respect to clinical assessment and treatment; relationships with the patients, caregivers, other specialists, and actors in the health care network; and information gathering and processing. A very interesting emergent finding from their study is that multimorbidity as measured by the Charlson comorbidity index was not a good predictor of episode complexity, as patients with multiple comorbidities often had simple hospital episodes while those without little comorbidity (low Charlson comorbidity score) had much more complex episodes with much less certain outcomes. The dynamics of those individual illness trajectories were not predicted by standard static disease based metrics nor supported by guidelines. Individual trajectories or journeys is a recurring theme in the developing CAS approaches in health care, representing the opportunity for responding to health status dynamics in a timely manner.7 This notion of intellectual work and time as markers of clinical complexity was also raised by Katerndahl et al in a previous analysis of medical work across clinical specialities.8 In complex systems, as the information in the input increases linearly, the complexity of the system increases exponentially. Thus, a simple rule is suggested, that clinical work complexity reflects the amount of care provided weighted by its diversity and variability. Primary care, because of its diversity and variability, scores highly on the amount of work demanded of its practitioners. In this theme, Fink et al9 describe the application of a clinical tool—Diagnostic Protocols (DP)—in a single handed practice over a 14-year period. Based on several decades of work by Braun and colleagues, DP represents a series of simple rules to reduce uncertainty in primary care presentations of serious conditions that may seem at first contact to be routine and non-serious. Here, we have the common theme of simple rules to identify courses of action related to simple and complex dynamics in patient trajectories over time in clinical care. At an organizational level, leadership is a crucial element of success, and its role is recognized as an important factor for achieving better performance and optimizing health improvements for patients. Horvat and Filipovic,10 using complexity leadership theory, identified three types of leadership and matched them to indicators of organizational maturity. Administrative leadership is grounded in traditional, bureaucratic notions of hierarchy, alignment, and control. Enabling leadership structures and enables conditions in which CAS can optimally address creative problem solving, adaptability, and learning. Adaptive leadership exemplifies a generative dynamic that underlies emergent change activities. Organizational maturity promotes organizational learning, enables effective and efficient management performance, reduces errors, and adapts to internal and external dynamics. Sustained success can be achieved by the effective management of the organization, through awareness of the organization's environment, by learning, and by the appropriate application of either improvements, or innovations, or both.11 Their survey of Serbian managers supported the hypothesis that administrative leadership had little influence on any maturity category of health care organizations. Adaptive and enabling leadership had greater association with managerial maturity. However, both adaptive and enabling leadership were also correlated with administrative leadership reflecting the entanglement of traditional structures and cultures of health care organizations with bottom-up informal emergent forces. A question that might be asked is: whether administrative leadership maintain the status quo by constraining emergence and self-organization to the detriment of organizational adaptability and learning? On an optimistic note, de Bock et al12 provide a case study of such bottom-up informal complex adaptive forces that successfully shifted clinical decision-making from professional silos into transdisciplinary inter-professional working. These shifts were driven by the internal and external tensions about caring for a longitudinal patient journey beyond technical rescue. The personal power of the nurses who were by the bedside, and their "bottom-up" understanding of the patient's needs, catalysed interdependent interactions and self-organization within the different professional groups. Care was thus adapted to patient-centred approaches beyond reductionist repair modes of thinking. This Forum highlights this emerging implementation of practical, but early stage CAS approaches to improving the outcomes of clinical care and health care more generally. To progress, a vision and practical goals for the shift needed from a conservative medical hierarchical disease focus, toward a more integrated biopsychosocial dynamic interactive ways of thinking about health.3 Tools to enable such implementation are needed, and four different practical approaches to deploy CAS theory in clinical care are highlighted that demonstrate innovation and adaptive thinking. They demonstrate a transition into enabling and adaptive leadership roles from the bottom-up. Yet the paper by Horvat and Filipovic provides some explanation about the slowness of the such transitions related to the challenges to complexity based leadership, with the ever-present dominant conservative health organizations. Administrative leadership models and cultures seeks to maintain the status quo and, for all intense and purposes, stand in the way of innovation and the emergence of "adapting and innovative" processes of care, system organization, and leadership. The International Organization for Standardization, a worldwide federation of national standards bodies (ISO member bodies), states that achievement of sustained success for any organization in a complex, demanding, and ever-changing environment requires enabling and adaptive leadership in health organizations.11 Health care will have to go through a huge cultural change to improve its organizational maturity with enabling and adaptive leadership. There is a need to successfully shape new ways of working and organizing in the evolution of health care. The role of adaptive leadership, as Ron Heifetz pointed out so eloquently, is not to solve problems, but rather to facilitate the necessary adaptive work of the people directly confronting the problems, often in the front-line in health care.13

Complex Adaptive Systems (CAS) are ubiquitous and composed of many interacting “agents” that exhibit independent properties and behaviors that function together with their environment to produce emergent properties. Emergence and emergent properties cannot be predicted by isolated understanding of these interacting agents/components; but can be demonstrated by observing the outcomes associated with dynamically changing interacting components of a CAS. Obviously, evolution also plays a key role in driving emergence as a defining feature of biological CAS. Biological CAS are highly heterogeneous and complex, both within and across broad scales of time and space. Biological CAS are also non-linear which means that predicting outcomes is difficult. Moreover, it is impossible to “fix” a CAS, rather the identification of leverage points that can alter the trajectory of the system to achieve desired outcomes is a more logical approach. Until recently, systems of such high dimensionality were not sufficiently tractable to understand and apply CAS principles to a disease as complex as cancer. However, recent progress in the development of advanced technologies such as computation, machine learning, artificial intelligence, and modeling portend a day when cancer will be viewed and managed as a CAS. These “big data” tools offer new and innovative opportunities to mine, manage, manipulate, model and simulate cancer to derive the information needed to manage it as a CAS. In terms of applying these principles at least one approach to treating cancer, immunotherapy, suggests that achieving a future state where cancer is viewed through the lens of CAS is well underway. Immunotherapy represents a paradigm shift in cancer therapy in that it targets the immune system, which is a quintessential CAS. When immunotherapy is successful the outcome is a “homeostatic reset” of what is an extraordinarily complex interaction between cancer and the immune system. Together these two complex systems comprise a CAS that promises to re-define how we treat and prevent cancer. A variety of immunotherapeutics (dominated by checkpoint inhibitors) have produced durable responses (possible cures) in a few patients against some cancers. These agents essentially block signals that the tumor employs to keep the immune system from recognizing and killing the cancer. However, the interaction of cancer and the immune system is a dynamic CAS that will ultimately require a detailed understanding of the cellular and microenvironmental changes that occur in patients in response to specific immunotherapeutic interventions. The challenges we face are significant including: identifying responders/non-responders; determining doses; predicting and controlling toxicities; developing rational combinations; and creating new targeted systems-based therapies. Fortunately, many of these challenges can be met by defining the “states” produced by some of the defining alterations observed in responsive and non-responsive patients including “omics” alterations, types of immune cells, temporal relationships, immune activation, humoral factors, etc. Although early, models and platforms to describe, annotate, model and simulate these systems alterations are emerging. In the past several years, we have developed a modeling platform that permits the study of the immune system and its interaction with cancer. “Cell Studio” is an immune-modeling engine that seeks to examine cancer and the immune response as a dynamic CAS by using real world data on the immune system and cancer to develop and inform computational models. Cell Studio permits the user to conduct in silico experiments of defined time and complexity. It combines agent-based and mathematical modeling approaches to capture multiscale dynamics within the immune system. The engine permits user creation of multiple different types of immune cells each with different classes of properties including different collections of cell surface receptors at different concentrations and affinities as well as the capacity to release and respond to cytokines. Multiple compartments corresponding to different body niches (e.g. lymph node, tumor environment) can be created. Mathematical models govern phenomena such as diffusion and cell tracking of cytokine gradients. As a CAS, based on a finite number of “rules” the system is self-organizing and can display emergent properties. User defined therapeutic interventions such as drug administration can be incorporated to assess the system’s response. Cell Studio is implemented using a gaming platform so that the in silico experiments can be visualized in 3D - in real time if desired. This permits researchers to perform experiments similar to those done using biologic model systems and visualizing the results. Like most video gaming platforms, different user views, overviews, individual cell movement, etc. are available and real-time as well as cumulative statistical outputs are captured and displayed. Unlike biologic model systems the simulations can be time reversed to identify, visualize, and manipulate key events. Experimentation using the Cell Studio modeling engine shows that it can recapitulate the longitudinal events in biologic model systems. Additionally, it can recover “immunophenotypes” observed in human studies of immunotherapy in cancer. It is anticipated that the in silico modeling can augment current biologic modeling strategies - especially since it can be run with numbers of replicates of virtual experiments that are not practical with biologic model systems. Additionally, it promises to assist in the rationale to develop combinatorial interventions hitting multiple immune targets and in understanding factors that modulate successful outcomes. In summary, the implications of viewing, studying and developing strategic approaches to fundamentally understand the cancer - immune system CAS are profound. Cell Studio is a next generation novel and powerful approach to analyze and model specific components of this dynamic and integrated CAS for the benefit of patients. Citation Format: Anna D. Barker, Kenneth Buetow. Viewing cancer as a complex adaptive system and managing immunotherapy as “homeostatic reset” [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr SY36-03.

Classical forest management has worked out a series of forest regulation methods with the aim of obtaining the “fully regulated” forest. Considering the forest as a complex biological adaptive system means overcoming the reductionist and mechanist paradigm, and entails a shift towards a systemic approach in silviculture and forest management. The aim of this work is to discuss the objectives and theoretical assumptions of classical forest management methods in the light of the new systemic paradigm. I conclude that managing forests as complex adaptive systems and sustaining their ability to adapt to future changes is possible only if there is also a change in forest management methods so that they are consistent with the new theoretical approach.

Applying Dynamic Simulation Modeling Methods in Health Care Delivery Research—The SIMULATE Checklist: Report of the ISPOR Simulation Modeling Emerging Good Practices Task Force

Bioeconomy is a complex economic system, the functioning of which leads to the emergence of a synergy effect due to the effective combination of natural resources and technologies along with the market-based, social, and political components. In a bioeconomic system, established links are formed between traditional industries based on the use of fossil natural resources and modern ones that have not previously intersected. As a result, one industry uses by-products of another industry as raw materials, thus forming a closed production cycle. The purpose of the article is to develop an author’s vision of the conceptual foundations to substantiate the sustainability of the bioeconomic system, taking into account its specific characteristics, modern challenges and potential of the country. The article reveals the features of transformations of socioeconomic systems into a complex adaptive bioeconomic system in a dynamic perspective. The complexity and complicacy of transformation management lies in the relationship and interaction of the elements of the system, as well as between the very system and its environment. A theoretical analysis of the evolution of the concept of «bioeconomy» is carried out and its basic properties are determined. The interpretation of the bioeconomy as a complex adaptive system that ensures the achievement of sustainable development goals is substantiated. Based on empirical data from the State Statistics Service of Ukraine and the European Commission, potential sectors of the bioeconomic sector of Ukraine have been identified, and the dynamics of the contribution of potential sectors of Ukraine’s economy to the national economy has been analyzed according to the main indicators: generation of value added and creation of jobs. Based on the theoretical and analytical research, it is proved that bioeconomy, as a complex system combining several sectors of the economy, can adapt to changes occurring in the environment.

It is well known in the literature how the modern health and care systems are being oriented to launch and develop national strategies to construct and build a more comprehensive system for the people with health and social care Most of Chronic Care programs have been introduced proactive care management for this vulnerable population who are causing high utilization of high cost services. However a new Integrated health and social care have been introduced in some countries and regions and there is a need of identifying these populations at risk with new and well accepted criteria and new care approaches in the field. This workshop will combine both the and implementation in related to proactive management of people with complex care needs from a joint health and social care perspective. 2 or 3 countries will be invited to explain main strategies and real implementation examples which could be easily escalated. An additional overview of Walter Wodchis as international expert and reviewer of different international national or regional best practices will be incorporated. We will introduce different issues related to - Earlier work of complex chronic health needs during implementation of Chronic Care programs. Some part of this work has started some time ago and experience of some yers could be - Evolution from the “complex health needs” toward a “complex health and social care needs” approach. New approaches to identify criteria related to complex social care needs will be explored especially related to the social care area. ·International overview of the most recognized innovative experience related to care for people with complex health and social care needs - Terminology required to talk properly about complexity: complexity, complex care needs, multimorbidity, complex health and social care needs,...? - Complex care in practice explaining which strategy is being developed to take care of people with complex health and social care needs from an “individual, team and territorial (county)” perspective - ICT developments to support work with different organizations and professionals who work collaboratively to manage people under a person centred model: introduction of Key Information Summary or Individual Intervention Plans to be shared by all organizations and professionals under a 24/7 scheme and other strategies - Evaluation of complex care strategy It would be introduced 2 or maybe 3 experiences and an additional international overview: - Catalonia and Scotland will talk about both policy and implementation in practice models which have priorised care approach - Walter Wodchis from Intitit oof Healt Policy, Management and Evaluation at University of Toronto speak about the most promising and innovative world experiences related to complex care (Walter Wodchis is co-author of the June issue of IJIC publishing 7 study cases related to complexity), showing lessons about these experiences and reccommendations for countries and regions developing and implementing Integrated Care for people with complex health and social care needs. This workshop will offer a combination of policy and implementation in practice issues and additionally an overview of the best practices in the world related to complex care

Supporting interoperability in complex adaptive enterprise systems: A domain specific language approach

Complex Adaptive Socio-Technical Systems The Role of Socio-Technical Networks in New Product Development

Specific protein associations define the wiring of protein interaction networks and thus control the organization and functioning of the cell as a whole. Peptide recognition by PDZ and other protein interaction domains represents one of the best-studied classes of specific protein associations. However, a mechanistic understanding of the relationship between selectivity and promiscuity commonly observed in the interactions mediated by peptide recognition modules as well as its functional meaning remain elusive. To address these questions in a comprehensive manner, two large populations of artificial and natural peptide ligands of six archetypal PDZ domains from the synaptic proteins PSD95 and SAP97 were generated by target-assisted iterative screening (TAIS) of combinatorial peptide libraries and by synthesis of proteomic fragments, correspondingly. A comparative statistical analysis of affinity-ranked artificial and natural ligands yielded a comprehensive picture of known and novel PDZ ligand specificity determinants, revealing a hitherto unappreciated combination of specificity and adaptive plasticity inherent to PDZ domain recognition. We propose a reconceptualization of the PDZ domain in terms of a complex adaptive system representing a flexible compromise between the rigid order of exquisite specificity and the chaos of unselective promiscuity, which has evolved to mediate two mutually contradictory properties required of such higher order sub-cellular organizations as synapses, cell junctions, and others – organizational structure and organizational plasticity/adaptability. The generalization of this reconceptualization in regard to other protein interaction modules and specific protein associations is consistent with the image of the cell as a complex adaptive macromolecular system as opposed to clockwork.

Work environment for nurses and the impact on protecting patients from health care errors.

This study aimed to analyse the concept of "complex adaptive systems." The construct is still nebulous in the literature, and a further explanation of the idea is needed to have a shared knowledge of it. A concept analysis was conducted utilizing Rodgers evolutionary method. The inclusive years of bibliographic search started from 2005 to 2015. The search was conducted at PubMed©, CINAHL© (EBSCO host©), Scopus©, Web of Science©, and Academic Search Premier©. Retrieved papers were critically analysed to explore the attributes, antecedents, and consequences of the concept. Moreover, surrogates, related terms, and a pattern recognition scheme were identified. The concept analysis showed that complex systems are adaptive and have the ability to process information. They can adapt to the environment and consequently evolve. Nursing is a complex adaptive system, and the nursing profession in practice exhibits complex adaptive system characteristics. Complexity science through complex adaptive systems provides new ways of seeing and understanding the mechanisms that underpin the nursing profession.