Complex Adaptive Systems - Health Foundation
Evidence scan:Complex adaptivesystemsAugust 2010Identify Innovate Demonstrate Encourage
ContentsKey messages31. Scope42. Concepts63. Sectors outside of healthcare104. Healthcare135. Practical examples186. Usefulness and lessons learnt24References28Health Foundation evidence scans provide information to help those involved in improving the qualityof healthcare understand what research is available on particular topics.Evidence scans provide a rapid collation of empirical research about a topic relevant to the HealthFoundation's work. Although all of the evidence is sourced and compiled systematically, they are notsystematic reviews. They do not seek to summarise theoretical literature or to explore in any depth theconcepts covered by the scan or those arising from it.This evidence scan was prepared by The Evidence Centre on behalf of the Health Foundation. 2010 The Health FoundationPreviously published as Research scan: Complex adaptive systems
Key messagesComplex adaptive systems thinking is an approach that challengessimple cause and effect assumptions, and instead sees healthcareand other systems as a dynamic process. One where the interactionsand relationships of different components simultaneously affect andare shaped by the system.This research scan collates more than 100 articlesabout complex adaptive systems thinking inhealthcare and other sectors. The purpose is toprovide a synopsis of evidence to help informdiscussions and to help identify if there is need forfurther research or development in this area.The scan suggests that a complex adaptive systemsapproach has something to offer when thinkingabout leadership and organisational developmentin healthcare, not least of which because it maychallenge taken for granted assumptions andprompt people to think in a less linear fashion.The key topic areas covered are:The most commonly suggested advantages of thisapproach are that it:–– How has complex adaptive systems thinkingcommonly been defined?–– How has this approach informed leadership andorganisational development in various sectors?–– How has this approach been applied in thehealth context?–– What practical initiatives use this approach?–– How useful is this way of thinking?The quantity and quality of research available islimited.Quality of evidenceRelevance to priorities across the UKPotential for use of this theory to havereal patient and cost outcomesQuantity of evidence available overallQuality of evidence available overallAvailability of other evidencesummaries and guidelines–– challenges assumptions–– focuses on relationships rather than simple causeand effect models–– can be applied in a variety of contexts–– provides a framework for categorising andanalysing knowledge and agents–– suggests new possibilities for change–– provides a more complete picture of forcesaffecting changeFrequently cited caveats include:–– not well defined or differentiated–– lack of empirical testing and use–– lack of comparison with other theories–– lack of predictive value–– used to justify a lack of intervention.There may be a need for a clearer definition ofthis approach and how it applies to healthcare,comparisons with alternatives and empiricalexploration of its value because most of theinformation available is descriptive rather thansolid research.Complex adaptive systems3
1 ScopeThe scan provides a rapid collation of empirical research aboutcomplex adaptive systems thinking.Although all of the evidence has been sourced and compiledsystematically, it is not a systematic review and does not seek tosummarise theoretical literature or to explore the concepts ofcomplex adaptive systems in any depth.1.1 PurposeThis research scan summarises readily availableresearch studies about or using complex adaptivesystems thinking, with an emphasis on howcomplex adaptive systems models have beenused to inform leadership and organisationaldevelopment approaches.The key topic areas covered are:–– How has complex adaptive systems thinkingcommonly been defined?–– How has complex adaptive systems thinkingbeen used to inform leadership andorganisational development in various sectors?–– How have complex adaptive systems approachesbeen applied in the health context?–– What practical initiatives have used complexadaptive systems approaches?–– How useful is complex adaptive systemsthinking?This section outlines the methods used to collateinformation. The following sections address each ofthe questions above briefly in turn.1.2 MethodsTo collate evidence, one reviewer searched 10bibliographic databases, reference lists of identifiedarticles and reviews, and the websites of relevantagencies for information available as at July 2010.The search, analysis and narrative synthesis werecompleted over a three week period.4THE HEALTH FOUNDATIONThe databases incorporated material from manydifferent disciplines and included MEDLINE,Ovid, Embase, ERIC, the Cochrane Library andControlled Trials Register, PsychLit, HealthStar,Google Scholar, the WHO library, HealthManagement Information Consortium and Sigal.All databases were searched from inceptionuntil present. Mesh terms and expanded keyword searches were used based around the termscomplexity, whole systems, adaptive leadership,working whole systems, and complex adaptivesystems.To be eligible for inclusion in the review, studieshad to be:–– primary research or reviews–– published research–– readily available online, in print or from relevantorganisations–– available in abstract, journal article, or fullreport form–– address one or more of the core questions.Studies in any language were eligible for inclusion.We scanned more than 50,000 pieces of research,selecting the highest quality and most relevantto summarise here. No formal quality weightingwas undertaken within the review, apart fromthe selection process outlined above. More than100 of the highest quality studies and descriptiveoverviews were synthesised.
Data were extracted from all publications usinga structured template and studies were groupedaccording to topic areas and outcomes to providea narrative summary of key trends. Meta-analysiswas not appropriate given the context of the reviewand the heterogeneity of the material. No otherdetailed empirical reviews specifically on this topicwere identified.When interpreting the findings it is important tobear in mind several caveats. First, the review isnot exhaustive. It presents examples of studies andinterventions but does not purport to representevery study about complex adaptive systemsthinking.Second, it is difficult to draw conclusions about theusefulness of this approach given the paucity ofempirical research. Even where empirical studieswere available, the level of detail was sometimesinsufficient to provide a meaningful summary.There is a paucity of comparativeevidence so it is difficult to say whethercomplex adaptive systems thinking ismore or less effective than alternatives.Third, the empirical evidence did not usuallyfocus on defining the approach and terms such as‘complexity theory’ and ‘complex adaptive systems’were sometimes used interchangeably. This meansthere is a lack of specificity and consistencysurrounding the material included.It is important to remember that a lack of evidencedoes not indicate a lack of effect or that theoriesor interventions are ineffective, just that there maybe few high quality studies available from which todraw conclusions.These caveats are all important when consideringthe synthesis of material overleaf.Complex adaptive systems5
2 ConceptsThis section describes some of the ways that complex adaptivesystems thinking and similar concepts have been defined and theprinciples or characteristics of the approach.2.1 Defining complexadaptive systemsIn its most simple form, complex adaptivesystems is a way of thinking about and analysingthings by recognising complexity, patterns andinterrelationships rather than focusing on causeand effect.The term ‘complex adaptive systems’ is thoughtto have been coined in the 1980s at theinterdisciplinary Santa Fe Institute, a New Mexicothink tank. However, this type of thinking hasbeen around for some time. For instance, in the19th century the Austrian School of Economicsdescribed how order in market systems isspontaneous (or emergent) and is not necessarilyplanned. In the 20th century the study of complexphenomena was further applied to humaneconomics, psychology, biology, cybernetics,anthropology and the natural sciences. Over thepast decade or so, the concepts have started to beused more extensively in healthcare, education andthe social sciences.1,2Proponents of this way of thinking suggest thatin the past researchers and planners have viewedthings in linear teams with simple rules of causeand effect. Analysts saw the world, organisations ortheir subject of study like a machine and thoughtthat if they took the machine apart and understoodthe components, then they would understand thewhole. It was also assumed that if each part wasmade to work better, then the whole would alsowork better. 36THE HEALTH FOUNDATIONSome planners and analysts have suggested thatmany things remain unpredictable and neednew styles of analysis, including the weather,ecosystems, immune systems and organisationaland human behaviour.In the field of quantum physics, researchers foundthat the very smallest sub nuclear particles werebehaving according to a different set of rules,not cause and effect. Investigators from manydifferent disciplines began to explore phenomenain similar ways and a new theory emerged knownas ‘complexity theory.’ Complexity theory is basedon relationships, emerging patterns and iterations.It suggests that the universe is full of systemssuch as weather systems, immune systems andsocial systems, and that these systems are complexand constantly adapting to their environment.Over the past decade or so, this way of thinkingabout systems has become known as the complexadaptive systems approach.The most common definition of a complex adaptivesystem, based on the work of John Holland, isa dynamic network of agents acting in parallel,constantly reacting to what the other agents aredoing, which in turn influences behaviour and thenetwork as a whole.4 Control tends to be dispersedand decentralised and the overall behaviour ofthe system is the result of many decisions madeconstantly by individual agents.5 Followingwork around neural networks, it is thought in acomplex adaptive system order emerges ratherthan being predetermined. It is not possible toreverse the system’s history and the future is oftenunpredictable.6
Others have defined this model as the study ofhow relationships between components giverise to the collective behaviours of a system andhow the system interacts and forms relationshipswith its environment. Other definitions focuson more physical components, such as seeingcomplex adaptive systems as collections of simpleinteracting units that have the ability to evolve tofit a changing environment.Complex adaptive systems thinking challengessome of the assumptions that policy makers,planners and researchers may take for grantedwhen interpreting things. These assumptionsinclude:7–– that every observed effect has an observablecause–– even the most complicated things can beunderstood by breaking down the whole intopieces and analysing it–– that if we analyse past events sufficiently, thiswill help to predict future events.These assumptions have been used when studyingthe physical world but proponents of complexadaptive systems theory suggest that they haveserved less well when exploring how communitiesof people interact and behave. Phrases such ascomplex adaptive systems, complexity science,complexity theory and complex evolving systemsare often used interchangeably. Some theoristssuggest that complex adaptive systems thinking is asubset of complexity theory or vice versa.8Complex adaptive systems [occurwhere] complex and patterned outputarises from simple, fundamentalprinciples, but requires many actorsand multiple interactions over time toproduce the emergent complexity. Yet,this characterisation represents only asample of the myriad of different facets ofcomplexity.9Others use the terms ‘complexity’ and complexadaptive systems interchangeably because theprinciples are thought to be similar or synonymousor because there is a lack of understanding aboutany differences between the two.The term ‘complex adaptive systems’ is usedthroughout the scan for consistency but it isacknowledged that some authors use ‘complexitytheory’ instead to describe the same principles.This way of thinking is not a single theory becauseit includes more than one theoretical frameworkand is interdisciplinary in nature.For convenience, this scan uses the terms theory,approach, model and way of thinking to describethe concept throughout, but it is acknowledgedthat the concept is not unilateral in nature and hasmany different definitions and approaches.2.2 System componentsComplex adaptive systems thinking suggests thatthe agents in any system are all the componentsof that system and interact and connect with eachother in unpredictable and unplanned ways. Forinstance, air and water molecules interact in aweather system and plants and animals interact inan ecosystem.This model believes that all of the interactionswithin systems begin to form emerging patternswhich in turn feed back into the system andfurther influence the interactions of the agents.Figure 1 (page 8) provides a visual representationof this process. For clarity the feedback processappears outside the system, but according to themodel it is an integral part of the system itself.There is no simple or most commonly useddefinition of complex adaptive systems, but thismodel of thinking tends to be guided by principlesand components listed on the following pages.Complex adaptive systems7
PatternFeedbackFeedbackRegularitiesAgentsFigure 1: simple representation of the components of a complex adaptive system102.3 PropertiesEmergenceThe characteristics of complex adaptive systemsinclude:The agents in the system interact in apparentlyrandom ways but from all of these interactionspatterns emerge which ultimately inform andchange the behaviour of the agents and the systemitself.–– a large number of elements which interactdynamically–– any element in the system is affected by andaffects several other systems–– non linear interactions, so small changes canhave large effects–– openness, so it may be difficult to define systemboundaries–– a constant flow of energy to maintain theorganisation of the system–– a history whereby the past helps to shape presentbehaviour–– elements in the system are not aware of thebehaviour of the system as a whole and respondonly to what is available or known locally.According to the literature, complex adaptivesystems have a range of properties, including thosedescribed on the following pages.8THE HEALTH FOUNDATIONCo-evolutionSystems are part of a broader environment soas the environment changes, systems change toensure best fit. This in turn influences the widerenvironment, and creates a constant cycle ofchange as the system develops to adapt to theenvironment and the environment changes asa result of system alterations. Some theoristsdistinguish between ‘complex adaptive systems’,which continuously adapt to the changes aroundthem but do not learn from the process, and‘complex evolving systems’, which learn and evolvefrom each change and thus help influence theirenvironment, predict likely changes and prepareaccordingly.
Others do not draw any distinction and insteadsuggest that ‘adaptive’ systems are also able tolearn.This signals that the Health Foundation and otherorganisations may need to consider the valueof using terminology such as complex evolvingsystems versus complex adaptive systems as a wayof conceptualising leadership and organisationaldevelopment.ConnectivityHow agents in a system connect and relate to oneanother is critical to the system’s survival and sothe relationships between the agents are usuallyseen as more important than the agents themselvesin complex adaptive systems thinking.Nested systemsMost systems are embedded within other systems.For example, a hospital is a system in itself withstaff, patients and carers, suppliers, partners,commissioners and neighbours. The hospital alsobelongs to a wider health system within its town orSHA region and the larger system of the NHS.Simple rulesComplex adaptive systems are not complicated andare often governed by simple principles.IterationSmall changes within a system can build like asnowball, leading to larger change.Sub optimalComplex adaptive systems do not have to beperfect and some suggest that any energy usedon being much better than alternatives is wastedenergy.Self organisingComplex adaptive systems do not have ahierarchy of command. They constantlyreorganise themselves to find the best fit with theenvironment.Edge of chaosComplex adaptive systems thinking is not exactlythe same as chaos theory, which is derived frommathematics, although there are some overlaps.Systems range from equilibrium to chaos. Thosesystems which are not able to respond to theirenvironment will cease to exist. Thus a system inchaos ceases to function as a system. Complexadaptive theory suggests that the most productivestate for a system is the ‘edge of chaos’ where thereis maximum variety and creativity.Based on these properties it could be argued thatcomplex adaptive systems are all around us, or thatwe are part of multiple complex adaptive systems.Principles such as self organisation and emergenceare what distinguishes a complex adaptive systemfrom other multi-agent systems, which are merelysystems composed of multiple interacting agents.In complex adaptive systems, the agents as well asthe system are adaptive.Examples of complex adaptive systems may includethe NHS, individual hospitals and healthcareorganisations, communities, political parties, thebrain, the immune system, ant colonies, the stockmarket, the ecosystem, developing embryos, andany human social group endeavour. However,some might argue that not all of these things shareevery characteristic of complex adaptive systems.Of the empirical studies investigated within thescan, few of the systems neatly or unquestioninglycorresponded to all of the properties listed here.Requisite varietyComplex adaptive systems thinking suggests thegreater the variety within the system, the strongerit is, and the more likely it is able to create newpossibilities and co-evolve.Complex adaptive systems9
3 Sectors outside healthcareThis section briefly outlines selected examples of how complexadaptive theory has been used to inform thinking about leadershipand organisational development in a range of sectors outsidehealthcare services.3.1 Using complex adaptivetheories in other sectorsThe descriptive literature is extensive so onlya selection of available material is included forillustrative purposes. Rather than describingleadership and organisational developmentin a narrow sense based on management orhierarchies, a much wider range of literatureabout organisational and system improvement isdescribed to give a flavour of varied topics covered.Much of the published literature availableabout complex adaptive systems thinking is notempirical. There are numerous articles describingthe perceived pros and cons of complex adaptivesystems approaches and postulating how thismodel may apply in various spheres such asmanagement, psychology, environmental science,the physical sciences, education and healthcare.These descriptions are based on the opinions andanalyses of the authors rather than grounded inempirical research. This research scan is focused onempirically based material.EngineeringWriters have examined how complex adaptivesystems might be used to understand the structuresand properties of objects and the people whouse them. Much of this work is descriptive ortheoretical, rather than applying the conceptsto leadership or organisational developmentpractically.1110THE HEALTH FOUNDATIONEconomicsResearchers have examined whether complexadaptive systems thinking can help explain thecharacteristics of market organisation and the rolesof leaders and others within this. For instance,researchers in China developed simulations to testwhether economic systems will self regulate togain the most efficient state of resource allocation.They found that efficient allocation of resourcescan occur despite a lack of communicationamong participants and used principles ofcomplex adaptive systems thinking to explain theunderlying reasons.12ManagementComplex adaptive systems thinking has been usedto investigate leadership styles, organisationalchange, team dynamics and sustainability.13-16For instance some authors have argued that inorder to be sustainable when there is no centralprovision of resources, organisations need tohave autonomous workers and staff that are fullyintegrated into the organisation. A comparison offour different pharmacy districts in the USA basedon interviews, staff questionnaires and balancedscorecard indicators found that comparing theautonomy and integration of systems was a usefulway to understand variation. The author concludedthat decentralised resource generation is oneway of obtaining sustainability. The coexistenceof autonomy and integration of employees, plustransformational leadership all encourage this.17
A literature review and case study in the USAexamined how managing organisations couldbe analysed using complex adaptive systemsthinking. Useful management features were foundto include a clearly formulated mission, delegationof responsibility and authority, diversity andcompetition, and follow up and feedback.18A number of management articles have exploredthe concept of ‘adaptive leadership’, whichrecognises and draws on the concepts of complexadaptive systems thinking. A study in Taiwanevaluated the impact of leadership styles onthe productivity of high technology industries.It examined the impact of adaptive and nonadaptive leaders on six measures of productivity:absenteeism, staff turnover rate, quality of work,reject rates, profitability and units produced. Inline with complex adaptive systems thinking, theresearchers found that the greater the level ofadaptability, the more productive the organisationis likely to be.19Urban plannersA case study in Canada found that complexadaptive systems approaches add value overtraditional accounts of cities and healthycities movements. In particular, the authorsconcluded that this way of thinking opens upfresh possibilities for improving health in urbancontexts.20Environmental scientistsExamples have been described from Sweden andCanada regarding the development of adaptiveco-management systems. They showed howlocal groups self organise, learn and adapt to andshape change with social networks that connectinstitutions and organisations. The authors foundthat institutional and organisational landscapesshould be approached as carefully as ecologicalfactors in order to identify features that contributeto the resilience of social-ecological systems. Thesefeatures include vision, leadership, and trust;enabling legislation that creates social space forecosystem management; funds for responding toenvironmental change and for remedial action;capacity for monitoring and responding toenvironmental feedback; information flow throughsocial networks; the combination of varioussources of information and knowledge; and sensemaking and arenas of collaborative learning forecosystem management.21Researchers in the USA examined the best formof leadership for advancing the integration ofconservation science into policy, management andsociety at large.Adaptive leadership principles were used toidentify essential traits including recognisingthe social dimension of the problem; cyclingfrequently through action and reflection; gettingand maintaining attention; combining thestrengths of multiple leaders; extending reachthrough networks of relationships; strategicallytiming efforts; nurturing productive conflict; andcultivating diversity.22EducationComplex adaptive systems thinking is gainingincreasing popularity and there are numerousexamples of how this model has been applied tohelp analysts think differently.23-27 For instance,authors in the US used a range of leadershiptheories to examine the role of school nurses.They concluded that school nurses can usetransformational leadership, situational leadershipand complex adaptive systems thinking to createpositive change in the school environment becauseall of these models recognise the need for flexibleleadership. Complex adaptive systems thinkingalso recognises the sometimes chaotic nature ofthe school setting, which requires organisationalleaders to be flexible and to identify and address itschanging needs.28A recently published qualitative study examinedthe implementation of health promotionprogrammes in primary schools in Australia.Complex adaptive systems thinking was used as aframework to help understand the ways in whichinterventions could be introduced and sustained.The authors examined whether schools exhibitcharacteristics of complex adaptive systems andComplex adaptive systems11
suggested that schools have most, but not all of thecharacteristics of such systems and have significantdifferences to artificial and natural systems. Theauthors concluded that understanding schoolsas social complex adaptive systems may help toexplain some of the challenges of introducingand sustaining change which in turn could helpimplement more sophisticated approaches to thediffusion of new programmes.29A range of generic material is also availabledescribing the potential role of complexadaptive systems in understanding leadershipand organisational development. This materialis not necessarily grounded in a particulardiscipline and most is descriptive or opinionorientated. For instance, US authors examinedhow organisations respond to surprise and whysurprise or uncertainty occurs. They suggestthat complex adaptive systems theory helps toexplain the challenges organisations face and thatcreativity and learning are two strategies to helporganisations deal with surprise.3012THE HEALTH FOUNDATIONIn the USA, RAND described using complexadaptive systems thinking as a tool for policyanalysis. The focus was on predicting whichpolicies will perform well, but this is somewhatat odds with the concept of complex adaptivethinking approaches that tend to focus ondescription and analysing possibilities rather thanpredicting effectiveness.31 This is an example ofhow the theory may be adapted and applied verydifferently from what might be expected from coredefinitions.3.2 SummaryQuality of evidenceQuantity of evidenceLowLowKey pointsComplex adaptive systems thinking has beenused to examine organisations and leaders in anumber of fields. Education and managementare the two fields outside health with the highestproportion of empirical research, but moretheoretical descriptions are prevalent throughoutother disciplines. Most of the available material isdescriptive rather than research based.
4 HealthcareThis section describes how complex adaptive systems thinkinghas been applied in the context of healthcare in the UK andinternationally. The focus is on briefly describing the range of topicareas to which this approach has been applied. Examples of practicalimplication are provided in the following section.4.1 Leadership andmanagementA number of authors have espoused the valueof leadership styles which use the principlesof complex adaptive systems thinking to makepositive changes by influencing context andrelationships.32In Sweden, authors suggest that complex adaptivesystems thinking could potentially help leadersto understand why the traditional top downway of managing may experience difficulties ininterdependent organisations with complex tasks.When we perceive health and socialservices as complex adaptive systemswe should gain more insight into theprocesses that go on within and betweenorganisations and how top management,for example within a hospital, in factexecutes its steering function.33Researchers in the UK and elsewhere havehighlighted the importance of connectivity,recursive feedback, diversity and self-orderingrules when analysing how to manage healthservices.34Authors in the USA have analysed leadershipfor change as an ‘activity’ rather than a positionof formal authority and focused on the beliefs,attitudes, and culture necessary to support adaptiveleadership. Resistance to change is described asa reaction to loss, which needs to be addressedthrough leadership activity and engagement.In order to sustain change and innovation, it isargued that leadership must be less accidental, lesstechnical and more adaptive.35It has been suggested that complex adaptivesystems thinking is useful for helping tounderstand clinician leadership as well asmanagerial leadership and can be applied to manydifferent facets of healthcare, from psychologyand mental health services through to biology andneurology.36,37 Important skills for clinical leadersinclude self awareness, shared authority, conflictresolution, and non punitive critique.38Researchers in the UK and elsewherehave highlighted the importanceof connectivity, recursive feedback,diversity and self-ordering rules whenanalysing how to manage healthservices.Complex adaptive systems13
4.2 OrganisationaldevelopmentIt has been suggested that systems that do notunderstand the principles of change managementfor complex adaptive systems continue to applychange models that have little chance of success.Understanding the principles and actions thatenable change in complex adaptive systems may beessential for long-term success.39Healthcare organisations have been described asmacro systems comprised of micro systems. Somehave argued that this means th
2.1 Defining complex adaptive systems In its most simple form, complex adaptive systems is a way of thinking about and analysing things by recognising complexity, patterns and interrelationships rather than focusing on cause and effect. The term 'complex adaptive systems' is thought to have been coined in the 1980s at the
Characteristics of Complex Adaptive Systems Complex Adaptive Systems A complex adaptive system is a system made up of many individual parts or agents. The individual parts, or agents, in a complex adaptive system follow
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