Health complexity

Approach and methodology

The Health Complexity Group has devised and implemented a unique methodology for evaluating change processes. The approach which we advocate in all of our evaluations confronts the conventional notion of evidence in an attempt to secure and describe the principal characteristics of transferability in the context of organisational change in health and social care. The conventional view – of organisations as machines – is no longer appropriate for understanding change. The machinic metaphors which form part of this approach, such as negative feedback and self regulation, need to be replaced by an emphasis on relationships and partnerships, by an exploration of context, and by understanding how each element in the programmes of change co-evolves in a continuing process of change. It is for these reasons that our programme of evaluation is informed by the principles of complexity. The principles of complexity have increasingly been cited to explain the nature of transformational change in national and multi-national corporations1, and at the level of national public policy2. More recently, complexity has been used as the explanatory basis for evaluating transformational change in healthcare organisations within the UK NHS3.

The approach, termed a constructive enquiry, is structured on three levels. First, a standard in depth qualitative case study is undertaken. Data will be collected by means of one-to-one semi-structured interviews, focus units, participant observation of relevant meetings, informal field notes, and scrutiny of written documents. The analysis at this level consists in coding of the ‘phenomena’ as described in the raw data, subsequent collation into higher order categories and themes, the latter representing major coherent concepts brought together from the participants’ accounts. At this stage, the researchers wherever possible ‘bracket’ any pre-conceived notions in order to classify the emerging themes in as neutral a way as possible. Data collected from interviews and focus units will be triangulated with the field note observations from meetings and appropriate written documents corresponding to the services.

This will be followed by a secondary analysis of this description using the evidentiary framework of complexity. Our ongoing research supports our proposal that processes of change can most clearly be understood from the perspective of complexity theory. Following this, a radically fresh third level of enquiry will entail a rigorous philosophical interrogation of the themes and analyses of the preceding two steps. It is this three level analysis which will permit the main themes of change to be systematically described; will substantiate the extent to which the process of organisational change thus described is illustrative of complex adaptive systems; and will rigorously consider the assumptions underlying the findings, and their implications for health care policy, discussing the findings in terms of necessary and sufficient conditions for change.

A key element in the research methodology consists in the formative process of iterative negotiated feedback, whereby initial findings will be discussed with participants, and their responses fed back into the data. Therefore, at regular intervals the qualitative analysis will be fed back to the participants, service users and the wider community which will enable the health community to actively learn from the ongoing research, discuss its implications and formulate a refreshed process of enquiry in conjunction with the researchers. In addition, the negotiated feedback will ensure the accuracy and relevance of the proposed research findings.

In summary, the three levels of the evaluation are:

  • Analytical: a standard qualitative case study at each site, collating data from a purposive sample of key informants, extended until data has been saturated, and analysed using a systematic grounded approach.
  • Interpretative: an examination of these themes form the perspective of complexity.
  • Philosophical: a rigorous philosophical analysis of the change process, whose purpose will be to distil the characteristics of the change process, examine any assumptions underlying these findings as well as the implications of our conclusions for policy.

In order to inform and support this three level analysis, data collection will proceed iteratively in a longitudinal time frame, allowing periodic analysis leading to interim conclusions, subsequent testing of themes, and gradual identification of emergent themes over time.

1 Wheatley M (2000) Leadership and the New Science. New York Barrett Koehler.

2 Glouberman S, Zimmerman B (2002) Complicated and Complex Systems: What would Successful Reform of Medicare Look Like? Discussion Paper 8. Commission on the |Future of Healthcare in Canada. Ottowa, Commission on the Future of Healthcare in Canada

3 See, for example, Durie R, Wyatt K, Fox M, Sweeney K (2004) Receptive context within the Pursuing Perfection Programme: a commentary from two sites. Report to the Modernisation Agency, DH.