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Designing and applying complex adaptive system principles to transformative change within John Hopkins Hospital means addressing serious system problems that undermine patient safety, redesigning systems of care that restrain shortages and differences of quality, as well as restructuring the work environment of the personnel. Complex adaptive systems principles for transformative change are multifarious in that they are composed of multiple, diverse interconnected elements. They are adaptive in that they have the capability to change and learn from their experience.
In line with complex adaptive systems principles, transformative change occurs in response to the external environment and involves some combination of factors associated with environment, leadership, mission and strategy, as well as John Hopkins Hospital’s organizational culture. Complex adaptive system for transformative change is a nonlinear system comprised of numerous connections and interdependence between diverse elements and independent agents that have the capacity to learn and adapt from experience (Cohn & Hough, 2008).
Complex adaptive system principles for transformative change can be applied in John Hopkins hospital in the study of clinical pathway development, the nursing professions resistance to change and medication errors in hospital (Burns, Bradley Weiner, 2011). Complex adaptive system can be applied to strategic change and implementation. Ribarsky (2009) indicated that with the complex interaction of multiple subsystems at multiple levels pursuing multiple strategic objectives, the performance of John Hopkins hospital is difficult to control and attempts to manage the system often produce unintended consequences.
The design and application of complex adaptive system at John Hopkins Hospital cannot be addressed through the process of hierarchical decomposition where solutions for individual component problems can be accomplished in a serial fashion until the total system reaches an optimal level of efficiency. Ribarsky (2009) noted that through designing a complex adaptive system the overall system behavior does change over time but they emerge out of the interaction of the important stakeholders. It is important to note that system changes in John Hopkins Hospital tend to be relatively unpredictable and uncontrollable, occasionally address a problem but often do not result in an innovative solution at times but just as often make things worse. Ribarsky (2009) studied that complex adaptive systems must be led rather than managed and that the abilities, limitations and inclinations of all stakeholders must be addressed. Within a complex adaptive system, relationship and connectedness are more important than individuality (Cohn & Hough, 2008).
Designing Complex Adaptive System Principles for John Hopkins Hospital
Johnson (2009) noted that when we view John Hopkins Hospital in the context of a complex adaptive system, new organizational characteristics come to the forefront. The designing of complex adaptive system (CAS) principles to transformative change encompasses change agents, interconnections, self organization, emergence and co-evolution. A change agent is a person who identifies the effective strategies that could be applied to transform a situation to the better one (Anderson & Anderson, 2001). For instance, while looking at the community context, it might be difficult for them to attain some services, but after intervening into such situation, it now becomes easy for them to attain such services (Connor & Stackman, 2003).
The first principle in the design of John Hopkins Hospital is the change agents. Johnson (2009) says that complex adaptive system makes up of a large number of diverse agents that are information processors. During the design of complex adaptive system there must be adequate diversity within the group of agents to enable the group to develop new solutions to problems and to make decisions in unique situations. In the design of complex adaptive system agents have the capacity to exchange information among themselves and with their environment and to adjust their own behavior as a function of the information they process. In John Hopkins Hospital, all players count, not only does each person contribute their talents, but they must help others contribute Johnson (2009).
The second aspect in the design of complex adaptive system is of interconnections. Johnson (2009) noted that the essence of a complex adaptive system is captured in the nonlinear relationships among agents. Mitsuishi, Ueda & Kimur (2003) noted that the need to be able to measure the complexity of a system, structure or problem and to obtain quantitative relations for complexity arises in John Hopkins Hospital. Design inputs are not proportional to outputs hence small changes within the hospital can lead to big effect and big changes can lead to small effects. Johnson (2009) for example noted that the way in which clinicians interact with each other, combined with the way they interact with non-clinicians is often a key determinant a healthcare organization’s ability to succeed. The new design should ensure that John Hopkins Hospital managers pay more attention to the relationship system than to the individual agents (Johnson, 2009).
Self organization principle plays a key role the design of complex adaptive system for the hospital. Johnson (2009) noted that complex adaptive systems are characterized by decentralized bottom-up process of co-design. He further says that new structures and new forms of behavior spontaneously emerge as agents self-organize themselves into relatively stable patterns of relationships. Johnson (2009) says that no matter how hard John Hopkins Hospital managers try to control certified nursing attendants, the attendants will organize themselves to do their job in the way that they see fit. Efforts to engage the stakeholders of John Hopkins Hospital in transformative change through complex adaptive system principles will help them to see the job better and to develop better skills at organizational analysis are likely to pay higher dividends than efforts to get them to toe-the-line.
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Another major principle in the design of complex adaptive system for transformative change in the hospital is emergence. Johnson (2009) noted that the behavior of a complex adaptive system cannot be obtained by summing the behaviors of the constituent parts, but emerge as a result of the pattern of connections among diverse agents. Emergence is a source of novelty and surprise in complex adaptive system. Johnson (2009) says that “when we treat safety and clinical success as emergent properties of the system, then we are more likely to be able to learn from the past behaviors of the system and develop alternative strategies for achieving the hospital goals” (p. 125).
The last significant principle in the design of complex adaptive system is co-evolution. Studies indicate that complex adaptive system does not simply change but it simply changes the world around them. Johnson (2009) explained that complex adaptive system and its environments convolve such that each fundamentally influences the development of the other. Johnson (2009) further says that complex adaptive system theory tells us that successful understanding of John Hopkins Hospital and the development of successful management strategies will involve the study of patterns and relationships rather than objects and substance, because it is the quality of the relationships among agents and between agents and their environment that most affect the quality of the system.
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Frndak (2008) mentioned that the key principles of complex adaptive systems that enable transformative change is that the system comprises large numbers of individual agents, the agents interact with each other according to rules that organize the interaction between them at a local level and agents endless repeat interaction referring back to their roles. Frndak (2008) also says that agent’s rules within John Hopkins Hospital will be such that the agents adapt to each other in a non-linear interaction. The entire process is always ongoing. There are four important agents in the design of complex adaptive system. These include payers, John Hopkins Hospital environment, doctors and patients.
Complex adaptive systems may be at one of the following three different stages on a continuum: static, edge of chaos and chaos. Tan & Payton (2010) noted that in static stage, the system experiences a period of order; if it fails to respond to changes in its environment, it can eventually expect to self destruct. At the edge of chaos, systems are constantly battling between static and chaos. They fluctuate randomly into static or chaos as feedback loops in these systems return them to one stage or the other in a seemingly random fashion. Tan & Payton (2010) noted that when functioning as complex adaptive systems, many hospitals cannot be entirely controlled. The following principles can help guide survival of the complex adaptive system as well as its progress. The principles include
- Major complex adaptive system changes may be achieved with small scale initial perturbation.
- System performance may be improved with appropriate feedback.
- In the static stage, standardization with flexibility maintains care quality.
- At the edge of chaos stage, shortened response time with backup redundancy improves effectiveness.
- In the chaos stage, intelligent and trustworthy leadership are essential.
In complex healthcare services delivery systems, for example, physicians will always have to act with a high degree of autonomy. For complex adaptive system to be accepted in John Hopkins Hospital, and diffused among physicians and nurses, standardized diagnostic or treatment protocols should never limit these professionals when confronting the unusual or unexpected (Tan & Payton, 2010).
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Applying Complex Adaptive System Principles in John Hopkins Hospital
Porter-O'Grady & Malloch (2010) indicated that applying complex adaptive systems principles for transformative change is especially challenging because by definition these systems operate within the continuous and unending dynamic change. While applying complex adaptive system, the management of John Hopkins Hospital should note that value becomes the driving force and management for value becomes the leadership process construct. Porter-O'Grady & Malloch (2010) further says that managing and leading to value means creating architecture to support that effort, one that focuses on outcome rather than process construct. Refocusing the constructs and dynamics of the system toward clinical outcomes will enable transformative change in the hospital.
Applying complex adaptive systems for transformative change in John Hopkins Hospital should focus on two significant issues which include structuring for constant change and developing and ensuring highly responsive and adaptive human behaviors and dynamics within the hospital construct (Porter-O'Grady & Malloch, 2010). To apply the complex adaptive system principles for transformative change requires a stronger and more seamless commitment to consistent organizational behaviors across the system. Porter-O'Grady & Malloch (2010) says that the focus of complex adaptive systems is on patience and agility rather than simply measures of efficiency. Since complex adaptive systems are dynamic and highly relational, the development of intense personal relationships and interactions is more critical to their success than has historically been valued.
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Consequently, Marshall (2010) described a universal cycle of transformation in the transitional period in John Hopkins Hospital as one driven by sociopolitical, economic, and technical forces toward the hospital’s adaptation from the industrial age to the age of technology. According to Marshall (2010) change within the hospital means to transform or to become something different. Managing change are efforts to maintain stability and contain the effects of unwanted or unexpected change. Change agents lead and support others in change by creating environments that promote desired change (Minai, Braha & Bar-Yam, 2010). Transformative change within the hospital is more effective when the complex adaptive system is framed as a pulling strategy, pulling people or attracting them toward promising possibilities rather than pushing or pressuring to move away from negative conditions (Minai, Braha & Bar-Yam, 2010).
In order to effectively apply complex adaptive system for transformative change within the hospital, the management of the hospital is required by administrative mandate to implement change. Marshall (2010) explained that important steps to encourage and promote local commitment to change includes creating a vision, expanding the target audience and broadening the power base to assure maximum engagement, keeping open communication with all areas of the organization. It is also important to create sense of urgency and manage the processes for successful change (Marshall, 2010).
Powerful principles of leading change in John Hopkins Hospital include eight steps for organizational transformation. Marshall (2010) noted that the first step is to establish a sense of urgency, form a powerful guiding coalition, create a vision, communicate the vision and empower others to act on that vision. The sixth step is to plan for and create short-term wins, consolidate improvements and produce more change and finally institutionalize new approaches (Marshall, 2010).
The complexity perspective suggests that through observation over time, it may be possible to identify what factors are important in bringing about a change in John Hopkins Hospital (Shemilt et al, 2011). A complex set of priorities, responsibilities, objectives, values and preferences drives transformative change about the hospitals resource allocation. Shemilt et al (2011) noted that applying complex adaptive system principles in transformative change should offer an alternative model for conceptualizing both the production of health, illness and recovery in populations within the hospital.
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In conclusion, Fulton & Lyon (2009) noted that some characteristics of complex adaptive system that limit transformative change in the hospital include its unpredictability, ambiguity, time pressure and stress laden situations, high stakes and decision making by teams with frequently changing members. While applying complex adaptive system there is a need to create a supportive transformative change environment within John Hopkins Hospital. Transformative changes at John Hopkins Hospital will occur with the help of supportive leadership that establishes a culture change, develops the capacity to implement transformation, including the expansion of infrastructure and allocation of resources, such as time, money and people.
It is fundamental to note that from these complex interactions emerge unpredictable behavioral patterns leading to small changes that may not lead to major wide spread changes. This implies that making transformative change in complex environments such as John Hopkins Hospital requires recognition and appreciation for the bi-directionality and unpredictability of system relationships including human technical and process. For transformation to occur in the context of complex adaptive systems, the management of the hospital should not confine their thinking to working only with people they know inside the organization or even by the usual professional networking.