Seite - 203 - in Applied Interdisciplinary Theory in Health Informatics - Knowledge Base for Practitioners

Because complexity tends to be inherent in healthcare programmes, the key challenge is often to develop ways of ‘running with’ complexity rather than seeking to eliminate it. The literature on complex systems suggests a number of strategies for running with complexity, including: strengthen programme leadership (and consider how to draw on distributed leadership to complement overall programme leadership); co- develop and sustain a clear and compelling vision for the programme while at the same time tolerating multi-stakeholder perspectives; identify and talk about uncertainty especially when it cannot be resolved; develop individuals and support the adaptive actions they take when implementing the programme at the front line; create incentives for delivering on broad objectives (but leave the detail to front-line staff) and provide them with slack resources (e.g. an accessible draw-down budget to use as appropriate); build relationships and manage stakeholder conflict; control programme growth (e.g. minimise scope creep); co-design pathways and work routines with intended end-users; acknowledge and respond to emergence, appreciating that unintended consequences will occur; and seek to better understand and work with the policy or regulatory context. In conclusion, we live in a world that is saturated with technology, yet the pervasive problems of non-adoption, abandonment and failure of scale-up, spread and sustainability of technology programmes show no signs of abating. Time after time, the strategic focus is drawn narrowly to the technology and actors are seduced by over- enthusiastic sales pitch and distracted by simplistic models and metaphors (e.g. ‘tipping point’). The dynamic socio-technical system into which new technologies and care practices must become embedded is overlooked or ignored – yet understanding and navigating its multiple interacting domains are key to programme success. Teaching questions for reflection 1. How would you define complexity? 2. What are the features of a complex adaptive system? 3. Using your own example of a health informatics project, identify key areas of complexity in the following domains: the condition or illness, the technology, the value proposition, the intended adopters, the organisation(s), the wider context and the embedding and adaptation of the technology and the programme-in-context over time. 4. Using your own example, consider how these areas of complexity could be either reduced or managed. References [1] T. Greenhalgh, J. Wherton, C. Papoutsi, et al., Beyond adoption: A new framework for theorizing and evaluating nonadoption, abandonment, and challenges to the scale-up, spread, and sustainability of health and care technologies, Journal of Medical Internet Research 19(11) (2017), e367. [2] T. Greenhalgh, J. Wherton, C. Papoutsi, et al., Analysing the role of complexity in explaining the fortunes of technology programmes: empirical application of the NASSS framework, BMC Medicine 16(1) (2018), 66. [3] S. Cohn, M. Clinch, C. Bunn, and P. Stronge, Entangled complexity: why complex interventions are just not complicated enough, Journal of Health Services Research & Policy 18(1) (2013), 40-43. [4] J. Braithwaite, R.L. Wears, and E. Hollnagel, Resilient Health Care Volume 3: Reconciling Work-As- Imagined and Work-As-Done, CRC Press, Boca Raton: FL, 2017. T.GreenhalghandS.Abimbola /TheNASSSFramework–ASynthesisofMultipleTheories 203