Complex Health Care System Research Articles

Comparison of Nurse-Midwife and Physician Birth Outcomes in the Military Health System.

The purpose of this study is to identify the socioeconomic and demographic characteristics of women cared for by Certified Nurse-Midwives (CNMs) versus physicians in the Military Health System (MHS) and compare birth outcomes between provider types. The MHS is one of America's largest and most complex health care systems. Using the Military Health System Data Repository, this retrospective study examined TRICARE beneficiaries who gave birth during 2012-2014. Analysis included frequency of patients by perinatal services, descriptive statistics, and logistic regression analysis by provider type. To account for differences in patient and pregnancy risk, odds ratios were calculated for both high-risk and general risk population. There were 136,848 births from 2012 to 2014, and 30.8% were delivered by CNMs. Low-risk women whose births were attended by CNMs had lower odds of a cesarean birth, induction/augmentation of labor, complications of birth, postpartum hemorrhage, endometritis, and preterm birth and higher odds of a vaginal birth, vaginal birth after cesarean, and breastfeeding than women whose births were attended by physicians. These results have implications for the composition of the women's health workforce. In the MHS, where CNMs work to the fullest scope of their authority, CNMs attended almost 4 times more births than our national average. An example to other U.S. systems and high-income countries, this study adds to the growing body of evidence demonstrating that when CNMs practice to the fullest extent of their education, they provide quality health outcomes to more women.

Faculty Formation: Philosophical Perspectives, Issues, and Considerations

With a looming nurse faculty shortage, it is imperative that schools of nursing develop and maintain the nurse educator workforce to meet the demands of today’s complex healthcare system. One component needed for workforce preparation is structure regarding formation of the faculty role. This article first defines faculty formation and why faculty formation is a relevant philosophical issue within nursing education. Next, we discuss current issues in faculty formation including: educational training; the orientation process; mentorship and role modeling; communities of practice; and faculty workload. We offer brief exemplars to illustrate current concerns with formation that faculty experience during role transition and recommend considerations for nurse leaders to support faculty formation.

Health Literacy and Psychiatric Hospital Readmission.

Health literacy (HL) is required for successful navigation of any complex health care system, and it is currently a public health problem. A large percentage of chronically mentally ill individuals have low HL. They are also at increased risk for hospital readmission and poor self-management skills. This study examined the HL of adult patients diagnosed with bipolar disorder, investigated the relationship between HL and psychiatric hospital readmission, and identified differences in readmission rates between HL groups. A prospective, exploratory, descriptive research design was used to examine readmission rates among 30 adult patients diagnosed with bipolar disorder: 16 men (mean age = 37 years, SD ± 12.16) and 14 women (mean age = 41.36 years, SD ± 12.51). The study used an HL questionnaire at or near discharge, and 2- and 4-weeks postdischarge readmissions were tracked. HL strongly correlated with 2-week and total readmissions. The findings support the feasibility of assessing HL further in this patient population, validate the procedure for subsequent studies, and provide preliminary data on the relationship between HL and readmission. The findings may also be useful for patient education, discharge planning, and policy making. [J Contin Educ Nurs. 2021;52(2):90-99.].

A Web-Based Application for Complex Health Care Populations: User-Centered Design Approach.

BackgroundAlthough eHealth technology makes it possible to improve the management of complex health care systems and follow up on chronic patients, it is not without challenges, thus requiring the development of efficient programs and graphic user interface (GUI) features. Similar information technology tools are crucial, as health care populations are going to have to endure social distancing measures in the forthcoming months and years.ObjectiveThis study aims to provide adequate and personalized support to complex health care populations by developing a specific web-based mobile app. The app is designed around the patient and adapted to specific groups, for example, people with complex or rare diseases, autism, or disabilities (especially among children) as well as Alzheimer or senile dementia. The app’s core features include the collection, labeling, analysis, and sorting of clinical data. Furthermore, it authorizes a network of people around the patient to securely access the data contained in his or her electronic health record.MethodsThe application was designed according to the paradigms of patient-centered care and user-centered design (UCD). It considers the patient as the main empowered and motivating factor in the management of his or her well-being. Implementation was informed through a family needs and technology perception assessment. We used 3 interdisciplinary focus groups and 2 assessment surveys to study the contexts of app use, subpopulation management, and preferred functions. Finally, we developed an observational study involving 116 enrolled patients and 253 system users, followed by 2 feedback surveys to evaluate the performance and impact of the app.ResultsIn the validated general GUI, we developed 10 user profiles with different privacy settings. We tested 81 functions and studied a modular structure based on disease or medical area. This allowed us to identify replicable methods to be applied to module design. The observational study not only showed good family and community engagement but also revealed some limitations that need to be addressed. In total, 42 of 51 (82%) patients described themselves as satisfied or very satisfied. Health care providers reported facilitated communication with colleagues and the need to support data quality.ConclusionsThe experimented solution addressed some of the health system challenges mentioned by the World Health Organization: usability appears to be significantly improved when the GUI is designed according to patients’ UCD mental models and when new media and medical literacy are promoted. This makes it possible to maximize the impact of eHealth products, thereby overcoming some crucial gaps reported in the literature. Two main features seemed to have potential benefit compared with other eHealth products: the modeling, within the app, of both the formal and informal health care support networks and the modular structure allowing for comorbidity management, both of which require further implementation.

Is the 'never event' concept a useful safety management strategy in complex primary healthcare systems?

A sub-group of rare but serious patient safety incidents, known as 'never events,' is judged to be 'avoidable.' There is growing interest in this concept in international care settings, including UK primary care. However, issues have been raised regarding the well-intentioned coupling of 'preventable harm' with zero tolerance 'never events,' especially around the lack of evidence for such harm ever being totally preventable. We consider whether the ideal of reducing preventable harm to 'never' is better for patient safety than, for example, the goal of managing risk materializing into harm to 'as low as reasonably practicable,' which is well-established in other complex socio-technical systems and is demonstrably achievable.We reflect on the 'never event' concept in the primary care context specifically, although the issues and the polarized opinion highlighted are widely applicable. Recent developments to validate primary care 'never event' lists are summarized and alternative safety management strategies considered, e.g. Safety-I and Safety-II. Despite their rarity, if there is to be a policy focus on 'never events,' then specialist training for key workforce members is necessary to enable examination of the complex system interactions and design issues, which contribute to such events. The 'never event' term is well intentioned but largely aspirational-however, it is important to question prevailing assumptions about how patient safety can be understood and improved by offering alternative ways of thinking about related complexities.

Coronavirus crisis and health care: learning from a service ecosystem perspective

PurposeThe COVID-19 pandemic has created a crisis for healthcare systems worldwide. There have been significant challenges to managing public and private health care and related services systems’ capacity to cope with testing, treatment and containment of the virus. Drawing on the foundational research by Frow et al. (2019), the paper explores how adopting a service ecosystem perspective provides insight into the complexity of healthcare systems during times of extreme stress and uncertainty.Design/methodology/approachA healthcare framework based on a review of the service ecosystem literature is developed, and the COVID-19 crisis in Australia provides an illustrative case.FindingsThe study demonstrates how the service ecosystem perspective provides new insight into the dynamics and multilayered nature of a healthcare system during a pandemic. Three propositions are developed that offer directions for future research and managerial applications.Practical implicationsThe research provides an understanding of the relevance of managerial flexibility, innovation, learning and knowledge sharing, which offers opportunities leading to greater resilience in the healthcare system. In particular, the research addresses how service providers in the service ecosystem learn from this pandemic to inform future practices.Originality/valueThe service ecosystem perspective for health care offers fresh thinking and an understanding of how a shared worldview, institutional practices and supportive and disruptive factors influence the systems’ overall well-being during a crisis such as COVID-19.

A review of implementation frameworks to operationalize health technology assessment recommendations for medical technologies in the Singapore setting.

Methodologies of health technology assessment (HTA) for medical technologies are well established; yet, operational frameworks that enable appropriate uptake of HTA recommendations into routine clinical practice are lacking. This review aims to identify the key themes needed to guide the planning and implementation of HTA subsidy decisions for medical technologies such as diagnostics, medical devices, and services and to monitor their impact on a complex multipayer healthcare system like Singapore. A literature search of implementation frameworks was conducted up to 20 December 2020 and was documented in a flow diagram. A thematic analysis of the evidence base was performed using the Braun and Clark approach to identify key themes, from which an implementation framework suitable for Singapore's healthcare system could be developed. The searches yielded forty-four articles for review, from which twenty themes were identified. The top ten themes constituted the key themes of implementation essential for local adaptation and were categorized into five domains: implementation strategy, organizational support, stakeholder engagement, information dissemination, and implementation outcomes and evaluation. These domains provide operational guidance to methodically identify gaps to facilitate sustainable implementation of HTA-informed medical technology subsidy decisions. A robust and adaptable implementation of HTA-informed subsidy decisions is crucial to optimize its intended impact of improving patient outcomes per dollar spent. The key themes of an implementation framework should capture the important aspects of organizational feasibility to ensure successful adoption in a complex multipayer healthcare system like Singapore.

Evaluation of System Modelling Techniques for Waste Identification in Lean Healthcare Applications.

PurposeWaste identification plays a vital role in lean healthcare applications. While the value stream map (VSM) is among the most commonly used tools for waste identification, it may be limited to visualize the behaviour of dynamic and complex healthcare systems. To address this limitation, system modelling techniques (SMTs) can be used to provide a comprehensive picture of various system-wide wastes. However, there is a lack of evidence in the current literature about the potential contribution of SMTs for waste identification in healthcare processes.MethodsThis study evaluates the usability and utility of six types of SMTs along with the VSM. For the evaluation, interview-based questionnaires were conducted with twelve stakeholders from the outpatient clinic at the Heart and Vascular Institute at Cleveland Clinic Abu Dhabi.ResultsVSM was found to be the most useful diagram in waste identification in general. However, some SMTs that represent the system behaviour outperformed the VSM in identifying particular waste types, e.g., communication diagram in identifying over-processing waste and flow diagram in identifying transportation waste.ConclusionAs behavioural SMTs and VSM have unique strengths in identifying particular waste types, the use of multiple diagrams is recommended for a comprehensive waste identification in lean. However, limited resources and time, as well as limited experience of stakeholders with SMTs, may still present obstacles for their potential contribution in lean healthcare applications.

Obstacles to diagnostic investigation of a child with comorbid psychiatric conditions.

Presented here is the unique case of diagnostic investigation for a 16 year old male presenting in an acute state of apparent psychosis. The patient had a long history of previous specialist work-ups, tentative diagnoses, multiple emergency department admissions, and medication trials, all of which failed to produce significant lasting relief. While initial encounters diagnostically centered on autoimmune encephalitis, comprehensive work-ups always drove the differential towards a likely psychiatric disorder. Despite this consistent professional opinion, tentative diagnosis of schizophrenia with underlying Autism Spectrum Disorder was delayed for many years, due to a variety of complicating factors. Overall, this case highlights many different considerations that might assist in avoiding a protracted road to diagnosis, including navigating the obstacles that parental interaction with a complex healthcare system can pose during diagnostic evaluation and recommended treatment as well as, the role of re-interpreting past test results within the context of new literature, and the complexities of diagnosing comorbid psychiatric conditions.

Patient navigation: fighting for the rights of breast cancer patients in Brazil

Introduction: The content of this article deals with the experience of the navigation program for patients in a breast cancer diagnosis center of the State Health Department of Rio de Janeiro. The objective was to show how the patient navigation program can allow the proper application of the 60-day Law, being a topic of interest for the planning and evaluation of actions to control this cancer in Brazil. Methodology: The patient navigator accompanied women from the Unified Health System (Sistema Único de Saúde — SUS) with a diagnosis of breast cancer to start treatment at a specialized center within 60 days. Information on the clinical characteristics of the patients, clinical dates and barriers encountered were collected. Univariate logistic regression was used to assess factors associated with starting treatment within 60 days. Results: From January to July 2020, 301 breast biopsies were performed, 126 (42%) of breast cancer. The mean age was 54 years (26–88). 75% of the lesions were diagnosed in advanced stages (IIB to IV). The mean time to start treatment was 39 days (11–108). The main barriers found were: fear (93%), difficulty in communicating with the medical team (81%), uncoordinated health care (37%). Being treated outside the city of Rio de Janeiro (RJ) was the main factor associated with treatment within 60 days (79.5% vs. 20.5%, p < 0.001). Conclusion: The integration of the patient browser into work processes contributed to compliance with the 60-day Law in 86% of cases. In the context of a complex and fragmented healthcare system for a population in a situation of socioeconomic vulnerability, the patient navigation program proves to be a tool to increase the rate of law enforcement in Brazil.

Preventing tipping points in high comorbidity patients: A lifeline from health coaches

Introduction/Background This pragmatic cluster randomized clinical trial (cRCT) enrolls patients with multiple chronic diseases (MCDs) who are at highest risk for destabilization (unplanned hospitalizations, increased disability). Patients with multiple chronic diseases are often excluded from clinical trials because of their multiple medical conditions and worse health outcomes, which significantly confound Results. Few evidenced- based strategies exist to comprehensively address the needs of these patients. Objective(s) Among 1920 adult patients with multiple chronic diseases defined as a Charlson Comorbidity Index (CCI) > 4, who are established primary care patients of 16 Federally Qualified Health Centers (FQHCs) in NYC (n=8) and Chicago (n=8), which serve predominantly low income, Black and Latino patients, this pragmatic cluster RCT evaluates the comparative effectiveness of two approaches to preventing significant destabilization ('tipping points') that leads to unplanned hospitalization and increased disability. Methods Federally Qualified Health Centers (FQHCs, n=16) are cluster-randomized to: 1) Patient Centered Medical Home (PCMH) (Usual Care);or 2) PCMH plus a Health Coach (PCMH + HC) intervention that employs a positive affect/ self-affirmation strategy to motivate patients to set life goals, improve self-management and handle psychosocial and other stressors (Experimental). Primary and secondary outcomes include: unplanned hospitalizations and emergency department (ED) visits aggregated by PCORnet Clinical Research Networks, Health Information Exchange (New York City), and hospital alerts (Chicago), at baseline, 6, 12, 24-months and changes in disability. With the COVID-19 pandemic, we shifted to remote recruitment, and added oral consenting, egift cards and mailed letters. Results The PCMH + HC arm is designed to identify and prevent destabilization leading to hospitalization or ED visits that are more often triggered by psychosocial issues-family, community and environmental-than by medical issues. The study is powered to detect a 33% relative reduction in% hospitalized (a 5% absolute reduction) in PCMH + HC compared to PCMH only. Additionally, we expect that reducing hospitalization will result in reduced disability. Conclusion This intervention is designed to help participants manage life events that lead to 'tipping points' or overwhelming situations that result in unplanned hospitalizations and increased disability. FQHCs with PCMH recognition focus on care coordination. Patients need assistance to deal with many social and health related challenges they face and need help in communicating with health care providers and navigating a complex health care system. The PCMH + HC intervention will determine if adding health coaches helps patients to better manage their sources of stress, improve self-care and reduce unplanned hospitalizations. The impact of COVID-19 on changes to study processes and patient outcomes will be examined.

The Journey: Nurses on Boards Coalition Preparation and Support Work Group.

Nurses have the knowledge, skills, and expertise to bring value and leadership to a myriad of boards throughout the United States, with nursing leadership critical to the transformation of complex health care systems. The 2011 Institute of Medicine Future of Nursing report calls on nurses to lead at all levels in systems as well as in board rooms. In 2014, the Nurses on Boards Coalition (NOBC) aligned its mission with this charge, creating a goal, as stated on its Web site, to "improve the health of communities and the nation through the service of nurses on boards and other bodies." A specific goal of NOBC was to have 10 000 nurses on boards by 2020. Through a partnership with the Robert Wood Johnson Foundation and the America Association of Retired Persons, NOBC worked strategically to achieve its goal. The accomplishments of one of its work groups, Preparation and Support, are highlighted.

The nurse’s role in the care of primary cutaneous lymphomas

Primary Cutaneous Lymphomas are a group of lymphomas that show complexity in diagnosis, clinical presentation and treatment. The aim of this review paper is to present the nurse’s role in the care of Primary Cutaneous Lymphomas, both as member of a multidisciplinary team, as well as an independent healthcare professional in the diagnosis, treatment, support of patients’ and in the management of the adverse complications. A review of the publications in Greek medical journals, nursing books, electronic databases of scientific societies and in pubmed and google scholar database, for the period from 2004 to 2018. From the papers found 53 were used. The nursing role is crucial, both in the initial diagnosis of the disease, as well as in the progress and treatment. The nurse’s role as a member of the multiprofessional team is emphafized, especially as nurse navigator. At the same time, the potential problems during treatment and the nursing interventions are presented. In conclusion, it is stated that a nurse can help solve many problems related to the understanding of symptoms and the course of the disease, but also be a supportive person for the patient and his/her caregiver. At the same time, the nurse is presented as a useful guide with the complexity of healthcare system.

A comparative study of patient and staff safety evaluation using tree-based machine learning algorithms

Medical errors constitute a significant challenge affecting patient and staff safety in complex and dynamic healthcare systems. While various organizational factors may contribute to such errors, limited studies have addressed patient and staff safety issues simultaneously in the same study setting. To evaluate this, we conduct an exploratory analysis using two types of tree-based machine learning algorithms, random forests and gradient boosting, and the hospital-level aggregate staff experience survey data from UK hospitals. Based on staff views and priorities, the results from both algorithms suggest that “health and wellbeing” is the leading theme associated with the number of reported errors and near misses harming patient and staff safety. Specifically, “work-related stress” is the most important survey item associated with safety outcomes. With respect to prediction accuracy, both algorithms provide similar results with comparable values in error metrics. Based on the analytical results, healthcare risk managers and decision-makers can develop and implement policies and practices that address staff experience and prioritize resources effectively to improve patient and staff safety.

Optimizing Kidney Replacement Therapy During the COVID-19 Pandemic Across a Complex Healthcare System.

The unprecedented surge of nephrology inpatients needing kidney replacement therapy placed hospital systems under extreme stress during the COVID-19 pandemic. In this article, we describe the formation of a cross campus “New-York Presbyterian COVID-19 Kidney Replacement Therapy Task Force” with intercampus physician, nursing, and supply chain representation. We describe several strategies including the development of novel dashboards to track supply/demand of resources, urgent start peritoneal dialysis, in-house preparation of kidney replacement fluid, the use of unconventional personnel resources to ensure the safe and continued provision of kidney replacement therapy in the face of the unanticipated surge. These approaches facilitated equitable sharing of resources across a complex healthcare-system and allowed for the rapid implementation of standardized protocols at each hospital.

Comparison of the prevalence of non-communicable diseases and traditional herbal medicine use in urban and rural communities in South Africa

BackgroundTo quantify the use of traditional herbal medicines (THM), we documented the prevalence of specific health conditions, the use of THM and the influences and reasons for using indigenous treatment practices. MethodsA cross-sectional descriptive study using a homogenous purposive sampling among 721 South Africans living in rural and urban black South African communities. A structured questionnaire was used to collect data between April–October 2014 on clinical/medical history, health-seeking behavior, and Traditional Herbal Medicine (THM) use. Descriptive, bivariate and multivariable analyses was done using R. ResultsMajority of participants (77.5%) were from the urban area. More than (90%) had no health insurance, and 80% had monthly income of< R2000 (equivalent to $ 126) in both urban and rural areas. Most participants had NCD irrespective of location, but prevalence was higher amongst urban dwellers (61%). Hypertension was found to be the most dominant cardiovascular disease risk factor. Rural participants had statistically significant higher rates of hypertension (67.1%) and diabetes (32.1%). Use of THM was significantly associated with recommendations by family or colleagues. Participants who reported poorer health status in rural areas used THM more than those in urban areas. Using multiple logistic regression, rural participants have greater than 12-to-1 odds of being THM users than urban participants (odds ratio [OR]=12.62; 95% confidence interval [CI]=(4.09, 55.34)). ConclusionsNCDs were more prevalent in urban communities with hypertension being the most prevalent. There is widespread use of THM across South Africa. Rural residents and individuals of low social economic status rely more on THM. These findings suggest a need for systematic and larger studies to understand the magnitude and predictors of variation in access to and use of healthcare services, as these are critical to developing effective culturally appropriate interventions for approaching hard-to-reach patients. Helping patients navigate the complex healthcare system is the hallmark of a responsive system of care.

Commentary on a “unified approach to behaviours that challenge”: getting it right? A family carer perspective

PurposeThe purpose of this paper is to provide an individual family-carer perspective on navigating the complex child, adult, education, health and social care systems focussing on what might be needed to get the right support in the right place at the right time for individuals with learning disabilities who display behaviour that challenges.Design/methodology/approachThis is a conceptual analysis, drawing on lived experience, policy and practice.FindingsPolicy and best practice advocate a holistic, person-centred, outcome-focussed approach to supporting individuals with learning disabilities whose behaviour challenges, but the existing complex multiple organisational structures are not conducive to delivering this. Making the system work for people requires focussed leadership across all levels to co-ordinate and align the component parts. It is certainly possible to achieve, but it is currently unclear who will take responsibility for making this happen.Originality/valueFamilies are often the only constant in the lives of people with disabilities. This commentary highlights what is important to and for families when attempts are made to get the right support in the right place at the right time for individuals with learning disabilities who display behaviour that challenges.

Doctors documenting: an ethnographic and informatics approach to understanding attending physician documentation in the pediatric emergency department.

The pediatric emergency department is a highly complex and evolving environment. Despite the fact that physicians spend a majority of their time on documentation, little research has examined the role of documentation in provider workflow. The aim of this study is to examine the task of attending physician documentation workflow using a mixed-methods approach including focused ethnography, informatics, and the Systems Engineering Initiative for Patient Safety (SEIPS) model as a theoretical framework. In a 2-part study, we conducted a hierarchical task analysis of patient flow, followed by a survey of documenting ED providers. The second phase of the study included focused ethnographic observations of ED attendings which included measuring interruptions, time and motion, documentation locations, and qualitative field notes. This was followed by analysis of documentation data from the electronic medical record system. Overall attending physicians reported low ratings of documentation satisfaction; satisfaction after each shift was associated with busyness and resident completion. Documentation occurred primarily in the provider workrooms, however strategies such as bedside documentation, dictation, and multitasking with residents were observed. Residents interrupted attendings more often but also completed more documentation actions in the electronic medical record. Our findings demonstrate that complex work processes such as documentation, cannot be measured with 1 single data point or statistical analysis but rather a combination of data gathered from observations, surveys, comments, and thematic analyses. Utilizing a sociotechnical systems framework and a mixed-methods approach, this study provides a holistic picture of documentation workflow. This approach provides a valuable foundation not only for researchers approaching complex healthcare systems but also for hospitals who are considering implementing large health information technology projects.

An intervention mapping process to increase evidence-based psychotherapy within a complex healthcare system.

In response to recommendations from the Special Committee on posttraumatic stress disorder (PTSD), the United States Department of Veterans Affairs, Veterans Health Administration (VHA) chartered a workgroup to identify strategies for improving the reach and fidelity of evidence-based psychotherapies (EBPs) implemented by VHA through clinician training initiatives. The workgroup, which comprised stakeholders in a variety of roles within the VHA, used an Intervention Mapping process, a practical approach to designing change strategies based on theory, evidence, and stakeholder input. High-level recommendations centered around implementation of recent VHA/Department of Defense (VA/DoD) treatment guidelines. In addition to recommended first-line and suggested second-line treatments, the guidelines include measurement-based care and shared decision making around EBPs and their alternatives to ensure that care is goal-oriented and patient-centered. To support increased reach and fidelity, the workgroup made four broad recommendations: (a) enhancing leadership support; (b) alignment of policies, programs, and processes that influence reach of EBPs as recommended in clinical practice guidelines, including implementation support to accompany EBP trainings; (c) use of clinical data to inform decision making at multiple levels, and to provide fidelity support when outcomes are lower than expected or desired; and (d) increasing veteran and stakeholder education and awareness of guideline recommendations and availability of EBPs. These recommendations accompanied a more detailed set of recommended steps for implementation. This article describes the Intervention Mapping process and a summary of resulting workgroup recommendations. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Making the invisible visible: a place for utilizing activity theory within in situ simulation to drive healthcare organizational development?

BackgroundThe healthcare needs of our societies are continual changing and evolving. In order to meet these needs, healthcare provision has to be dynamic and reactive to provide the highest standards of safe care. Therefore, there is a continual need to generate new evidence and implement it within healthcare contexts. In recent times, in situ simulation has proven to have been an important educational modality to accelerate individuals’ and teams’ skills and adaptability to deliver care in local contexts. However, due to the increasing complexity of healthcare, including in community settings, an expanded theoretical informed view of in situ simulation is needed as a form of education that can drive organizational as well as individual learning.Main bodyCultural-historical activity theory (CHAT) provides us with analytical tools to recognize and analyse complex health care systems. Making visible the key elements of an in situ simulation process and their interconnections, CHAT facilitates development of a system-level view of needs of change.ConclusionIn this paper, we theorize how CHAT could help guide in situ simulation processes—to generate greater insights beyond the specific simulation context and bring about meaningful transformation of an organizational activity.