Healthcare as a complex adaptive system

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chapter 2: Literature review

There is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than the creation of a new order of things.
Niccolo Machiavelli, 1513

 Introduction

There are three parts to this chapter. The first explores the nature of systems and examines health care and the District Health Boards (DHB) within the health system as complex adaptive systems. DHBs are organisations that contain multiple components or agents that interact and influence one another. This indicates that Systems Theory and particularly Complex Adaptive Systems Theory provides a tool for interpreting and understanding behaviour within DHBs and encouraging the emergence of change readiness, demonstrated by change ready behaviours on the part of organisational members.
The second part of this chapter explores the application of Contingency Theory (an offshoot of Systems Theory) and performance management in the context of change. Contingency Theory provides insights into the best ways to manage events to achieve desired outcomes, such as change readiness, through the study of recurring situations. The recurring situations relevant to this study are the six separate implementations of the interRAI Home Care comprehensive geriatric assessment (interRAI-HC) tool at each of the six DHBs participating in this study. Performance measurement and management act as an enablers of change readiness by providing feedback to stakeholders on the achievement of desired goals. Accordingly, this chapter will review literature regarding performance management including the multi-stakeholder, multi-dimensional view of performance relevant to the complexity of DHBs.
In the final section, this chapter reviews literature regarding the importance of change readiness to the success of change events, the factors influencing change readiness at the various organisational levels, the constructs of change readiness and instruments used to assess all or part of an organisation’s state of readiness to implement change, including examples developed for the healthcare industry. This section also outlines the development of a State of Readiness Tool for use in complex health care settings (the main product of this research). First, however, definitions of the more commonly used terms in the thesis are outlined.

 Definitions and terms

Adoption: This study will consider adoption (or introduction) of an innovation, new technology, process or practice by an organisation as a discrete organisational decision to accept an innovation or change event (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). Such adoption by an individual shall be considered as the decision of an individual to make full use of innovation or change as the best course of action available (Rogers, 2003). Adoption or introduction of a change event into an organisation or service may not lead to its assimilation into normal daily working routine.
Ageing in place: The concept of ‘ageing in place’ is linked to policy responses to an ageing population such as those contained in the following statement by health and social policy ministers of the OECD in 1994, “elderly people, including those in need of care and support should, wherever possible, be enabled to continue living in their own homes, and where this is not possible, they should be enabled to live in a sheltered and supportive environment which is as close to their community as possible, in both the social and geographical sense.” (Organisation for Economic Co-operation and Development, 1994, p. 3).
New Zealand’s policymakers have described ageing in place as “the ability to make choices in later life about where to live, and receive the support to do so” (Dalziel, 2001, p. 10). Contextually, this description refers to an older person’s ability to remain living in the community, including within retirement villages but it explicitly excludes living in residential care.
Assimilation: Assimilation is an organisational process that is set in motion when individual organisation members first hear of an innovation’s development, can lead to the acquisition (adoption) of the innovation and sometimes comes to fruition in the innovation’s full acceptance, utilisation and institutionalisation (A. D. Meyer & Goes, 1988).
Carer or Care Giver: This study uses the definition of “carer” provided by the Ministry of Health in New Zealand: “a person, usually a family member, who looks after a person with a disability or health problem and who is unpaid for providing this service” (Ministry of Health, 2002, p. 78).
Change recipient: In this study, this term refers any person impacted or affected by a planned change event.
Complex Adaptive System: A complex adaptive system is a collection of individual agents with freedom to act in ways that are not always predictable and whose actions are interconnected so that one agent’s actions changes the context for the other agents (Plsek & Greenhalgh, 2001, p. 25).
Disability support services: In New Zealand, disability support services constitute a range of services for people with disabilities and their families to increase independence and participation in the community (Ministry of Health, 2004a). Services include residential care, assessment, treatment and rehabilitation services (AT&R), carer support, environmental support and home care services.
Health care: The World Health Organization (WHO) broadly defines health care as: “The purpose of health services is to promote health; to prevent, diagnose and treat diseases – whether acute or chronic, whether physical or mental in origin – and to rehabilitate people incapacitated by disease or injury” (Abel-Smith, 1963, p. 24). Health care is described by the Organisation for Economic Co-operation and Development (OECD) as ‘The sum of activities performed either by institutions or individuals pursuing, through the application of medical, paramedical and nursing knowledge and technology, the goals of: promoting health and preventing disease; curing illness and reducing premature mortality; caring for persons affected by chronic illness who require nursing care; caring for persons with health related impairment, disability, and handicaps who require nursing care; assisting patients to die with dignity; providing and administering public health; and providing and administering health programmes, health insurance and other funding arrangements” (Organisation for Economic Co-operation and Development, 2000, p. 42).
Health System: A health system is the combination of resources, organisation, financing and management that culminate in the delivery of health services to the population (Roemer, 1990). In New Zealand, publicly funded healthcare is mainly funded or delivered by District Health Boards. By 2015 there were 20 DHBs in New Zealand’s publicly funded health system. These organisations are Crown entities, accountable for planning and funding health and disability support services to meet the needs of the population within a specific geographic area.
interRAI-HC tool super-user: This is a person who has undergone extensive training in the use and interpretation of the interRAI-HC assessment tool and who has considerable experience in its use and application to service coordination and allocation.
Older People or Older Person(s): The Oxford English Dictionary (« Old, » 2007), defines old as “Having lived or existed for a relatively long time” (p. 1993). Tinker (1993) contends there is little agreement with respect to a specific age at which people should be considered ‘old’. In New Zealand, the retirement age is 65 years and those reaching this age are often considered ‘old’. At this age a person can access disability support services funded by District Health Boards. Therefore, in this study the terms ‘older people’ or ‘older person(s)’ shall refer to those aged 65 years or more.
Personal Health Services: These are services provided by health professionals to treat or advise on health conditions and include district nursing services provided in the community, general practitioner services and hospital inpatient and outpatient services (Ministry of Health, 2004b).
Support Allocation (SPA) Tool and Support Needs Level Assessment (SNL) Tool: These are tools used nationally in New Zealand to assess the disability support needs of older people. These tools were replaced by the interRAI Home Care comprehensive geriatric assessment (interRAI-HC) tool in District Health Boards participating in this study.
Technology and Process: This study is about the creation of readiness to implement complex process into organisations, principally DHBs, delivering healthcare in New Zealand. While new processes often involve the introduction of new technology, the word ‘technology’ is hard to define because it is used to describe a variety of things, actions, processes, methods and systems (S. J. Kline, 1985; Liagouras, 2010). Most narrowly, the term refers to the interaction between the research and development department and other departments in a firm (S. Kline & Rosenberg, 1986). More broadly, ‘technology’ is the sum of technical knowledge in an economic unit such as an organisation, region or country and more broadly still ‘technology’ encompasses the totality of technical and organisational knowledge in an economic unit (Liagouras, 2010). It is in the widest sense that the term ‘technology’ is used in this study.
Similarly, numerous definitions of the word “process” have been proposed (Palmberg, 2009). Hammer (1990) and Davenport (1993) describe a process as beginning with an input or inputs and resulting in an output, defining a process as a structured set of activities designed to produce an output. However, Sandhu and Gunasekaran (2004) view processes in horizontal and cross functional terms and Isaksson (2006) describes the components of a process as a set of repeatable interrelated activities, involving the use of resources and offering purpose or value to customers. Cascini, Rissone, and Rotini (2008) view business processes as technical systems that generate value by converting available resources into products or services. Palmberg (2009) provides a definition of the term ‘process’ as a horizontal sequence of activities that transforms an input (need) to an output (result) to meet the needs of customers or stakeholders. It is with reference to (Palmberg, 2009) definition that the term process is used in this study, noting that technology or technical know-how is usually an input into a process.
It is noteworthy that when first introduced to DHBs, the interRAI-HC tool was regarded as new technology. This was because of the electronic nature of the tool. However, once assimilated into normal business activity, ‘new’ technology is generally considered a component of a process. Likewise, the interRAI-HC tool is now seen as process rather than technology by study participants and the wider health system. That is, it is seen as the new process for assessing the disability support needs of older people. This illustrates the potential inter-changeability of the terms technology and process, particularly over time. When referring to ‘new’ processes or ‘new’ technology, the term ‘new’ with respect to this study means that it is new to the organisation(s) in question, in this case the six participating DHBs. It may not be new to the health or any other system or organisation.

Literature search

An electronic literature search was performed to obtain journal articles and other manuscripts for this study. The search covered a variety of databases relevant to the disciplines of management, medicine, nursing, allied health, psychology, education, defence, strategic and military science and the science of systems. Most articles were obtained from the following databases: Ovid Medline(R), Embase, Economic Literature database, Emerald Management Xtra, Health Improvement and Innovation Resource Centre, Cochrane Library, MEDLINE Ovid SP, Psyc/INFO and Sage Full Text Journal Collections. Manual literature searches were undertaken in the Philson library at the University of Auckland and the library of the Ministry of Health in Wellington, New Zealand. Additional online searches were undertaken using the Google (http://www.google.com) and Google Scholar (http://scholar.google.co.nz) search engines. Searches used key words and phrases such as ‘blue ocean’, ‘contingency’ ‘adopting and assimilating’, ‘new technology’, ‘interRAI’, ‘adopting/assimilating’, ‘change readiness’ ‘process’, ‘implementation’, ‘technology’, ‘diffusion’, ‘innovation’, ‘state of readiness’, ‘human factors’, ‘Systems Theory’. ‘Complex Adaptive Systems’, ‘healthcare’, ‘health systems’ ‘funding’, ‘ageing population’, ‘change management’, ‘social change’, ‘health care reform’, ‘health policy’, ‘learning organisation’ , ‘service improvement’, ‘implementation success factors’ ‘organisational culture’, ‘organisational performance’ and ‘balanced scorecard’.

The scope of the literature review

This study is principally concerned with the creation and emergence of (change) readiness to implement planned change events in DHBs and similar complex organisations or (social) systems delivering healthcare. Organisations delivering health care can be considered complex systems to which systems thinking can be applied to understand behaviour (R. Atun, 2012). The idea of the emergence of adaptive behaviour within organisations in response to a particular set of conditions such as those associated with a planned change is a central concept of Systems and Complexity Theories (R. Atun, 2012; Ellis, 2011) and more particularly that branch of Systems Theory concerned with Complex Adaptive Systems (Ellis, 2011). Consequently, a review of Systems Theory, Complexity and Complex Adaptive Systems Theory will be a focus of this Chapter. Another branch of general Systems Theory of interest to this study is Contingency Theory. Contingency approaches to the management of organisations involve the study of recurring situations and observing how different strategies, processes and structures affect the desired outcome. These approaches aim to identify the responses that best deliver the desired outcome (for example maximising readiness to implement a planned change) in a given situation. Contingency Theory provides a useful bridge between Systems Theory and performance management. Organisational, group and individual responses to contingencies affect both the emergence and regression of change readiness and improvement and deterioration in organisational performance. Performance management is regarded as a key enabler of change (Colville & Millner, 2011; A. de Waal, A., 2003).

Chapter I: Introduction
1.1 Introduction
1.2 The publicly funded health system in New Zealand
1.3 Funding the public health sector in New Zealand
1.4 Pressures for change in the health system
1.5 The interRAI assessment toolkit
1.6 NASC services and disability support services for older people
1.7 The phases of research
1.8 Study participants
1.9 Thesis organisation and contribution to knowledge
Chapter 2: Literature review
2.1 Introduction
2.2 Definitions and terms
2.3 Literature search
2.4 The scope of the literature review
2.5 Defining a system
2.6 General Systems Theory and organisations
2.7 Complexity and Complexity Theory
2.8 Complex adaptive systems
2.9 Healthcare as a complex adaptive system
2.10 Contingency Theory and implications s
2.11 Performance management and measurement; overview
2.12 Performance management and measurement; the balanced scorecard
2.13 Change readiness, exploring the context
2.14 Change readiness, exploring the significance
2.15 Factors influencing change readiness – overview
2.16 Change readiness – definitions and constructs
2.17 Assessment of change readiness
2.18 Developing a SoRT
2.19 Summary
2.20 Research aims and questions
Chapter 3: Methodology
3.1 Introduction
3.2 Research methodology paradigms
3.3 The researcher
3.4 Qualitative research
3.5 Case study methodology
3.6 Data analysis
3.7 Summary
Chapter 4: Methods
4.1 Introduction
4.2 Ethical approval and informed consent
4.3 The study participants
4.4 The research design
4.5 Thematic analysis: reliability and validity
4.6 Study timeline
4.7 Summary
Chapter 5: This case study
5.1 Introduction
5.2 The participating District Health Boards
5.3 The need for change
5.4 Failure or absence of a health system-wide, complete change message
5.5 Painting the picture of success
Chapter 6: The development of SoRT
6.1 Introduction
6.2 Adoption does not always lead to assimilation
6.3 Overview of the development of SoRT
6.4 Step One – Environmental pre-introductory change readiness
6.5 Step Two – Creating organisational pre-introductory change readiness
6.6 Step Three – Change readiness to fully adopt the change event
6.7 Step Four – Change readiness to assimilate the change event
6.8 Summary
Chapter 7: Usability of SoRT
7.1 Introduction
7.2 The utility of the SoRT
Chapter 8: Discussion
8.3 What does success look like to participants?
8.4 What are the characteristics that determine change readiness?
8.5 How can a State of Readiness Tool support implementation?
8.18 Limitations
8.19 Conclusions
8.21 Implications
8.21.1 Implications for national policy
8.21.2 Health service implications
8.22 Future research
Appendices
References
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