The mental demands of leadership in complex adaptive systems

Petrie, David; Swanson, R. Chad

doi:10.1177/0840470418778051

Cited by 14 publications

(11 citation statements)

References 27 publications

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“…As shown in Area South, mid-level managers can role-model leadership practices that both deepen the health system software recognized as important for resilience ( Gilson et al, 2017 ; Kagwanja et al, 2020 ) and distribute leadership. Listening, being respectful, allowing others to lead and creating spaces for learning from experience are important practices of leadership in complexity and for resilience ( Belrhiti et al, 2018 ; Petrie and Swanson, 2018 ). These practices can strengthen the commitment and motivation of staff to innovate, learn, adapt and transform.…”

Section: Discussionmentioning

confidence: 99%

“…These practices can strengthen the commitment and motivation of staff to innovate, learn, adapt and transform. In addition, the Area South manager did two other things acknowledged to support resilience in complex systems ( Chamberland-Rowe et al, 2019 ; Petrie and Swanson, 2018 ). Alongside the CityHealth Director, she worked up the bureaucracy to leverage some slack in the system - specifically, a relaxation in compliance demands and additional resources for PHC improvement - and she pro-actively sought to use data to nurture system awareness.…”

Section: Discussionmentioning

confidence: 99%

“…Central level actions must enable complex health systems to self-organize towards agreed goals. Such actions could include: adapting the boundary conditions influencing the system ( Petrie and Swanson, 2018 ) e.g. in Area South, relaxing compliance demands and resource challenges; decentralizing authority, unlike in Area South, to allow local level leaders to reward experimentation ( Cloutier et al, 2016 ); and, as demonstrated in Area South, supporting the development of relational leadership skills among future mid-level and senior managers ( Gilson and Agyepong, 2018 ).…”

Section: Discussionmentioning

confidence: 99%

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Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

Gilson

Ellokor

Lehmann

et al. 2020

Social Science & Medicine

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This paper reports a study from Cape Town, South Africa, that tested an existing framework of everyday health system resilience (EHSR) in examining how a local health system responded to the chronic stress of large-scale organizational change. Over two years (2017–18), through cycles of action-learning involving local managers and researchers, the authorial team tracked the stress experienced, the response strategies implemented and their consequences. The paper considers how a set of micro-governance interventions and mid-level leadership practices supported responses to stress whilst nurturing organizational resilience capacities. Data collection involved observation, in-depth interviews and analysis of meeting minutes and secondary data. Data analysis included iterative synthesis and validation processes. The paper offers five sets of insights that add to the limited empirical health system resilience literature: 1) resilience is a process not an end-state; 2) resilience strategies are deployed in combination rather than linearly, after each other; 3) three sets of organizational resilience capacities work together to support collective problem-solving and action entailed in EHSR; 4) these capacities can be nurtured by mid-level managers’ leadership practices and simple adaptations of routine organizational processes, such as meetings; 5) central level actions must nurture EHSR by enabling the leadership practices and micro-governance processes entailed in everyday decision-making.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

Gilson

Ellokor

Lehmann

et al. 2020

Social Science & Medicine

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“…By approaching these issues with a CASs informed mindset, 41 and moving the metaphor from the ED being a negative/passive canary in the coal mine, to being a more active/positive catalyst for change in the broader health system, perhaps we can improve the way we address access and flow problems in the ED (and the entire health system), and improve outcomes for the patients and populations that we serve.…”

Section: Resultsmentioning

confidence: 99%

Emergency Department access and flow: Complex systems need complex approaches

Petrie

Comber

2020

Evaluation Clinical Practice

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Hospital access block, often referred to as Emergency Department (ED) overcrowding when it manifests there, is an important public health issue and seemingly intractable problem in our evolving healthcare systems. 1 The multiple, dynamic, and interdependent factors influencing its cause (and potential solutions) may best fit a complex adaptive systems (CASs) analysis and approach. Complex adaptive systems differ from simple systems in the number of components, the degree of interconnectedness between and among those components, and the certainty of a working solutions. Complicated systems lie some place in the middle but would still operate with predictable and controllable characteristics. While this categorization itself may be an oversimplification, it is clear that simple/complicated systems have different properties (linear cause-and-effect, predictable outcomes), and behave differently than complex systems (non-linear and difficult to predict). 2-4 These different properties have a significant impact on problem formulation and solving. In fact, not recognizing how complex systems behave has limited attempts at health system "transformation" 5 and complex issues management. 6 For example, our approach to the opioid crisis 7 and the obesity crisis 8 started with siloed and doomed-to-fail linear approaches but have now recognized the complexity of the problem. 9 This suggests that we need to shift our mindsets, and improve our systems thinking, as we address the health system problems that have proven resistant to conventional approaches. These shifts in thinking may significantly impact a Health System's approach to ED access block. 10 Understanding the number of components and degree of inter-dependencies in the system may bring to the fore previously under-emphasized, or even unrealized, strategies and solutions.

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“…Delivery of health care and leadership of health care organisations were influenced by machine metaphors and Newton's clockwork universe. The central idea to the machine metaphor was that the health system is a mechanical system with defined boundaries, linear functions and in which outputs can be predicted [28,125]. Newton's clockwork universe was based on universal laws of motion and gravity in which the whole system can be broken into parts and the behaviour of the whole could be understood, controlled and predicted by studying each part [28,125].…”

Section: Health As a Complex Adaptive Systemmentioning

confidence: 99%

Implementation of large-system transformation initiatives in the New Zealand health system

Sharma¹

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Health systems worldwide are trying to shift towards a learning system to deliver people-centred, holistic and equitable health care. Large-system transformation (LST) initiatives that capitalise on key features of complex adaptive systems may be more likely to achieve the desired shift. By LST initiatives, I mean “interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes” (p 422) [1]. This research had three aims: (1) to identify the key elements that support successful implementation of LST initiatives; (2) to construct a maturity matrix that describes different stages of maturity for each of these elements; and (3) to investigate and report on contextual factors that influence successful implementation of LST initiatives. Collectively, the three aims revealed the programme architecture that underpins efforts to successfully implement LST initiatives in the New Zealand health system. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research. This research used insights from a New Zealand LST initiative (the System Level Measures programme), evidence from literature, and evidence from knowledge of those working in the health system, to analyse and describe this programme architecture. The research resulted in three key sets of findings. First, the research found that a set of 10 key elements needs to be present in the New Zealand health system and work in harmony to increase the chances of successful implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to Te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whanau and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) an integrated health information; (ix) analytic capability; and (x) dedicated resources and time. Second, a self-assessment maturity matrix for the key elements was developed with New Zealand health system leaders to provide a practical tool for them and informal trust-based networks (such as Alliances) to improve their understanding of the different stages of maturity for the key elements, to assess their readiness for change, and to develop capacity and capability needed for system transformation. Third, a realist logic of enquiry was used to investigate how the key elements work in different contexts to influence the successful implementation of LST initiatives. At a local level, (i) the history of working together and quality of relationships, (ii) distributed leadership from commissioners of health services, and (iii) the maturity of informal trust-based networks, such as Alliances, emerged as key contextual factors that influenced successful implementation of these initiatives. The key mechanism of trust was triggered with a positive history of working together, which built strong relationships and facilitated a distributed leadership style among health system agents through informal networks. The high-trust environment built and nurtured over time strengthened relationships among health system agents, which then provided the foundation for health system transformation. At a national level, the distributed health system leadership, the application of ‘new power’ approach to design and implementation of LST initiatives, and the system accountability environment emerged as key contextual factors. The existing accountability framework, which solely focussed on financial performance of District Health Boards and outputs, suffocated the notion of a learning system as health system leaders placed more effort on achieving targets and outputs rather than on continuous improvement. A culture of continuous improvement supported the notion of a learning system; it encouraged iterative learning using methods such as plan-do-study-act cycles and fostered innovation. Use of ‘new power’ values such as collaborative policy design and implementation harnessed the intrinsic motivation of health system agents and built trust between policy makers and health service providers, which lead to sustained collective engagement with transformation efforts. A collective engagement to achieve a shared vision built strong and resilient health system leadership. The research concluded that transformation of health systems depended on senior system leaders’ understanding of the programme architecture that underpins efforts to successfully implement LST initiatives.

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The mental demands of leadership in complex adaptive systems

Cited by 14 publications

References 27 publications

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa

Emergency Department access and flow: Complex systems need complex approaches

Implementation of large-system transformation initiatives in the New Zealand health system

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