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Improvements in neonatal and paediatric care mean that many children with complex care needs (CCNs) now survive into adulthood. This cohort of children places great challenges on health and social care delivery in the community: they require dynamic and responsive health and social care over a long period of time; they require organisational and delivery coordination functions; and health issues such as minor illnesses, normally presented to primary care, must be addressed in the context of the complex health issues. Their clinical presentation may challenge local care management. The project explored the interface between primary care and specialised health services and found that it is not easily navigated by children with CCNs and their families across the European Union and the European Economic Area countries. We described the referral-discharge interface, the management of a child with CCNs at the acute–community interface, social care, nursing preparedness for practice and the experiences of the child and family in all Models of Child Health Appraised countries. We investigated data integration and the presence of validated standards of care, including governance and co-creation of care. A separate enquiry was conducted into how care is accessed for children with enduring mental health disorders. This included the level of parental involvement and the presence of multidisciplinary teams in their care. For all children with CCNs, we found wide variation in access to, and governance of, care. Effective communication between the child, family and health services remains challenging, often with fragmentation of care delivery across the health and social care sector and limited service availability.

Purpose – This chapter frames the topic of organizing for sustainable health care in terms of the environmental trends that have rendered current health care approaches unsustainable, the embeddedness of health care in society's triple bottom line, and the need to build adaptive capability within the complex health care ecosystem.

Design/methodology/approach – We synthesize documented trends and empirical findings regarding the viability of current approaches to health care, and provide a theoretically framed treatment of the adaptation process in the complex health care system that can lead to the emergence of sustainable approaches.

Findings – There is a misfit between current approaches to delivering health care and the requirements and trends in contemporary society. Fundamental transformation is required that entails a broadening of purpose, a future orientation, and a rethinking of how health care adds value and how it is embedded in society.

Originality/value – By reconceptualizing health care reform as intricately related to societal sustainability and the triple bottom line, we open the possibility of transcending a narrow focus on reengineering to create more efficient organizations and work processes that consume fewer resources and deliver greater value. We invite health care practitioners and scholars to rethink all the connections in the health care ecosystem, and the need to build in self-organizing capabilities and adaptive capacity. The cases in this book provide knowledge from systems engaged in fundamental transformation, analyzed through the lenses of theoretical frameworks that help us better understand essential dynamics involved in creating sustainable health care systems.

The purpose of this paper is to describe research that examined physician leadership development using complexity science principles.

Intensive interviewing of 21 participants and document review provided data regarding physician leadership development in health-care organizations using five principles of complexity science (connectivity, interdependence, feedback, exploration-of-the-space-of-possibilities and co-evolution), which were grouped in three areas of inquiry (relationships between agents, patterns of behaviour and enabling functions).

Physician leaders are viewed as critical in the transformation of healthcare and in improving patient outcomes, and yet significant challenges exist that limit their development. Leadership in health care continues to be associated with traditional, linear models, which are incongruent with the behaviour of a complex system, such as health care. Physician leadership development remains a low priority for most health-care organizations, although physicians admit to being limited in their capacity to lead. This research was based on five principles of complexity science and used grounded theory methodology to understand how the behaviours of a complex system can provide data regarding leadership development for physicians. The study demonstrated that there is a strong association between physician leadership and patient outcomes and that organizations play a primary role in supporting the development of physician leaders. Findings indicate that a physician’s relationship with their patient and their capacity for innovation can be extended as catalytic behaviours in a complex system. The findings also identified limiting factors that impact physicians who choose to lead, such as reimbursement models that do not place value on leadership and medical education that provides minimal opportunity for leadership skill development.

This research provides practical applications for physician leadership development and emphasizes that it is incumbent upon physicians and organizations to focus attention on this to achieve improved patient and organizational outcomes.

This study pairing complexity science and physician leadership represents a unique way to view the development of physician leaders within the context of the complex system that is health care.

The purpose of this paper is to reflect on the experience of the Advancing Quality Alliance's (AQuA) regional Integrated Care Discovery Community created to translate integrated care theory into practice at scale and to test ways to address the system enablers of integrated care.

Principles of flexibility, agility, credibility and scale influenced Community design. The theoretical framework drew on relevant complexity, learning community and change management theories. Co-designed with stakeholders, the discovery-based Community model incorporated emergent learning from change in complex adaptive environments and focused bespoke support on leadership capability building.

In total, 19 health and social care economies participated. Kotter's eight-step change model proved flexible in conjunction with large-scale change theories. The tension between programme management, learning communities and the emergent nature of change in complex adaptive systems can be harnessed to inject pace and urgency. Mental models and simple rules were helpful in managing participant's desire for a directive approach in the context of a discovery programme.

This is a viewpoint from a regional improvement organisation in North West England.

The Discovery Community was a useful construct through which to rapidly develop multiple integrated health and social care economies. Flexible design and bespoke delivery is crucial in a complex adaptive environment. Capability building needs to be agile enough to meet the emergent needs of a changing workforce. Collaborative leadership has emerged as an area requiring particular attention.

Learning from AQuA's approach may assist others in structuring large-scale integrated care or complex change initiatives.

The needs of complex patients with chronic conditions can be unpredictable and can strain resources. Exploring how tasks vary for different patients, particularly those with complex needs, can yield insights about designing better processes in healthcare. The purpose of this paper is to explore the tasks required to manage complex patients in an anticoagulation therapy context.

The authors analyzed interviews with 55 staff in six anticoagulation clinics using the Systems Engineering Initiative for Patient Safety (SEIPS) work system framework. The authors qualitatively described complex patients and their effects on care delivery.

Data analysis highlighted how identifying complex patients and their effect on tasks and organization, and the interactions between them was important. Managing complex patients required similar tasks as non-complex patients, but with greater frequency or more intensity and several additional tasks. After complex patients and associated patient interaction and care tasks were identified, a work system perspective was applied to explore how such tasks are integrated within clinics and the resulting implications for resource allocation.

The authors present a complex patient management framework to guide workflow design in specialty clinics, to better support high quality, effective, efficient and safe healthcare.

The complex patient framework presented here, based on the SEIPS framework, suggests a more formal and integrated analysis be completed to provide better support for appropriate resource allocation and care coordination.

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

Purpose – This chapter provides a reflective synopsis of the chapters in the volume and highlights the learning from the cases about the development of new orientations, design configurations, and learning mechanisms. It charts directions for further research and possible managerial actions.

Design – The chapters in this second volume of the book series “Organizing for Sustainable Effectiveness” capture a rich set of cases in which organizing for sustainable health care was the central focus. Each chapter illuminated the development of a distinct health care system in a unique cultural and national context, and had a special focus on reporting theoretically informed and rigorously explored knowledge to guide purposeful design and learning approaches. Collectively the chapters highlighted the processes, organization and design, system regulation, and continuous learning approaches in complex organizational and multi-organizational health care systems that enable focus on and advancement of economic, social, and ecological outcomes.

Findings – Several critical themes have emerged from the cases, and from the broader literature on health care transformation: the importance of purpose; the need to overcome fragmentation; the need for alternative business models; technology as an investment in sustainable health care; the centrality of knowledge management; the importance of partnership and collaboration; the role of self-organization and leadership; and the criticality of building change capabilities.

Purpose – This chapter argues that health care is best conceptualized as a complex adaptive system. Sustainable health care depends on harnessing the complexity of the system by building aligned purpose, flexible pathways to connect people, knowledge and resources, and the capacity for self-organization.

Design/methodology/approach – The case study of the Southern California Region of Kaiser Permanente is based on three years of interviews and archival data collection examining the system's transformational change that began in 2004 and has been aimed at building a sustainable health care system with the guiding principles of value and prevention. The case focuses primarily on the medical care delivery system designed by the Southern California Permanente Medical Group, the capabilities that have been built into the system to continually improve the quality of care and the outcomes of the system, and the results that have been achieved.

Findings – During the period from 2004 to 2011, the region improved significantly in slowing cost acceleration by significantly improving medical care. The implementation of an electronic medical records system and its integration with other clinical information technology systems have enabled: (1) truly integrated, well defined, and easily navigated care delivery systems that are based on evidence; (2) upstream focus on prevention, disease control, patient education, and population health; and (3) management accountability and organizational improvement systems based on transparency of data and feedback. Physician leadership and partnering with the region's administrative and hospital leadership have been critical change enablers.

Originality/value – Embracing the complexity of the system has led to the crafting of pathways and linkages that enable patients to move through the system to flexibly and efficiently connect to the knowledge and resources required to optimize their health. This requires continual self-organization based on well-defined roles and connections. Previous health care improvement approaches have stressed initiatives and organizational changes that may further fragment the health care system.

Recent reports by the Institute of Medicine (IOM) signal a substantial yet unrealized deficit in patient safety innovation and improvement. With the aim of reducing this dilemma, we provide an introductory account of clinical error resulting from poorly designed systems by reviewing the relevant health care, management, psychology, and organizational accident sciences literature. First, we discuss the concept of health care error and describe two approaches to analyze error proliferation and causation. Next, by applying transdisciplinary evidence and knowledge to health care, we detail the attributes fundamental to constructing safer health care systems as embedded components within the complex adaptive environment. Then, the Health Care Error Proliferation Model explains the sequence of events typically leading to adverse outcomes, emphasizing the role that organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction. Subsequently, we discuss the critical contribution health care leaders can make to address error as they strive to position their institution as a high reliability organization (HRO). Finally, we conclude that the future of patient safety depends on health care leaders adopting a system philosophy of error management, investigation, mitigation, and prevention. This change is accomplished when leaders apply the basic organizational accident and health care safety principles within their respective organizations.

While theories of complex service systems have advanced important insights about integrated care, less attention has been paid to social dynamics in systems with finite resources. This paper aims to uncover a paradoxical social dynamic undermining the objective of integrated care within an HIV care service system.

Grounded in a hermeneutic analysis of depth interviews with 26 people living with HIV/AIDS (PLWHA) and drawing on Bourdieu’s (1984) theory of capital consumption to unpack dynamics of power, struggle and contestation, the authors introduce the concept of the service labyrinth.

To competently navigate the service labyrinth of HIV care, consumers adopt capital consumption practices. Paradoxically, these practices enhance empowerment at the individual level but contribute to the fragmentation of the HIV care labyrinth at the system level, ultimately undermining integrated care.

This study enhances understanding of integrated care in three ways. First, the metaphor of the service labyrinth can be used to better understand complex care-related service systems. Second, as consumers of care enact capital consumption practices, the authors demonstrate how they do not merely experience but actively shape the care system. Third, fragmentation is expectedly part of the human dynamics in complex service systems. Thus, the authors discuss its implications. Further research should investigate whether a similar paradox undermines integrated care in better resourced systems, acute care systems and systems embedded in other cultural contexts.

Contrasted to provider-centric views of service systems, this study explicates a customer-centric view from the perspective of heterosexual PLWHA.