Performance management in complex adaptive systems: a conceptual framework for health systems

Abstract

Existing performance management approaches in health systems in low-income and middle-income countries are generally ineffective at driving organisational-level and population-level outcomes. They are largely directive: they try to control behaviour using targets, performance monitoring, incentives and answerability to hierarchies. In contrast, enabling approaches aim to leverage intrinsic motivation, foster collective responsibility, and empower teams to self-organise and use data for shared sensemaking and decision-making.The current evidence base is too limited to guide reforms to strengthen performance management in a particular context. Further, existing conceptual frameworks are undertheorised and do not consider the complexity of dynamic, multilevel health systems. As a result, they are not able to guide reforms, particularly on the contextually appropriate balance between directive and enabling approaches. This paper presents a framework that attempts to situate performance management within complex adaptive systems. Building on theoretical and empirical literature across disciplines, it identifies interdependencies between organisational performance management, organisational culture and software, system-level performance management, and the system-derived enabling environment. It uses these interdependencies to identify when more directive or enabling approaches may be more appropriate. The framework is intended to help those working to strengthen performance management to achieve greater effectiveness in organisational and system performance. The paper provides insights from the literature and examples of pitfalls and successes to aid this thinking. The complexity of the framework and the interdependencies it describes reinforce that there is no one-size-fits-all blueprint for performance management, and interventions must be carefully calibrated to the health system context.

Linking resilience and regulation across system levels in healthcare – a multilevel study

“…This is a novel output in the research field because few studies have examined and contradicted the assumption that regulation and resilience are intractable opposites [ 6 – 9 ]. A regulatory and supervisory system that aims at regulating processes, through checking that hospitals are adequately undertaking quality improvement, can be considered both a better fit for a complex system and should also build resilience (and responsiveness to local conditions) through being more enabling of adaptations to local risks [ 6 , 61 ]. As such, the performance-based regime investigated in our study, has great potential in being flexibly applied into hospital management and quality improvement processes.…”

“…On the other hand, autonomy and freedom to tailor improvement efforts require competence, additional resources, and systems to support hospitals and hospital managers, and responsible application by the regulatees [ 39 , 40 , 69 , 70 ]. System’s “software”, including organizational culture, adequate management, and leadership, has shown to be a crucial determinant of quality improvement performance [ 61 , 71 ]. For instance, micro-level noncompliance to implementation may link with a lack of management competences [ 72 ].…”

“…Thus, these capacities’ purpose, namely, to corroborate system resilience, depend on central government support in budget allocations, as well as regional and local administered support to competence building and resources in general. Enabling factors that make performance management constructive have previously shown to be teamwork, self-organizing practices, and shared sensemaking [ 61 ]. These collaborative processes call for a double loop learning process.…”

Characterising performance information use in the primary healthcare systems of El Salvador, Lebanon and Malawi: multiple qualitative case study protocol

“… 17 Enabling approaches are guided by logics of improvement and learning; can create conditions for adaptive and iterative cycles of error, reflection, sensemaking and corrective action; and conceive of performance as emergent processes, influenced by managers and workers’ agency, motives, means and opportunities. 18 19 …”

“…Directive systems tend to be guided by a logic of consequences, are prevalent in systems that favour audit cultures,16 are designed with a view towards accountability and follow the utility-maximising assumptions of Homo economicus in agency theory 17 . Enabling approaches are guided by logics of improvement and learning; can create conditions for adaptive and iterative cycles of error, reflection, sensemaking and corrective action; and conceive of performance as emergent processes, influenced by managers and workers’ agency, motives, means and opportunities 18 19…”