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Health System Redesign: Applying Complex Adaptive Systems Approaches

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Health system redesign, as argued in this book, is based on three fundamental assumptions:

  • The philosophy of medicine—the value of health services arises from its impact on the health of the people we treat

  • The person/patient is at the centre of a functional complex adaptive health system

  • A seamlessly integrated health system has to understand its purpose, goals, and values to devise its unique “simple (operating) rules”. These together determine the core driver for the “system as a whole” as exemplified by the Mayo Clinic’s motto: “The needs of the patient come first”.

    This overarching principle does not prevent a health system’s subsystems to adopt their own drivers. However, they need to contribute to the seamless integration of meeting the health system’s overall objectives

This chapter illustrates how people/person-centred complex adaptive systems thinking and interventions can guide the redesign of novel approaches at every organisational level.

At the service delivery (micro) level:

  • Clinical care in the consultation. Drawing causal loop diagrams can provide important insights into the dynamics of a person’s illness. The deeper understanding about the linkages between the biological, social, emotional, and cognitive state of the person’s current illness experience allows a clinician to more effectively integrate the management of the personal, environmental, and medical domains.

  • Preventing avoidable hospitalisation of the frail elderly. Monitoring the daily changes in frail elderly patients’ health experiences can identify those at risk of avoidable hospitalisation. The main reason resulting in avoidable hospitalisation, surprisingly, is the perception of lack of social support rather than actual deterioration in organ specific function.

  • Guidelines can be unworkable. When identified, a process known as “positive deviance” allows those affected to quickly develop novel approaches that achieve the desired outcomes. Positive deviance entails (1) to acknowledge that there is a problem, (2) that every individual is part of the problem, (3) that there are barriers to change, and (4) that collective conversations amongst all involved will result in better solutions.

At the community (meso) level:

  • Health system redesign at the community level, particularly in disadvantaged ones, requires community consultation. Since health is a personal experience understanding what impacts on the people’s and community’s health is essential. For example, the most disadvantaged community in Sydney identified community development and renewal, employment skills and opportunities as well as community safety as the top priorities for the improvement of their health.

  • Community health invariably requires a multi-pronged approach. The “Shape up Somerville” initiative exemplifies this approach. The nutrition department worked with schools to improve pupils’ nutrition knowledge and adapted the canteen’s food offerings. The next step engaged the City Council to improve walk and cycle ways as well as play and sports grounds. Optimisation of the school bus routes allowed more kids to safely walk to the next bus stop rather than needing to be driven to school, and working with food outlets identified those willing to offer healthy food choices.

At the policy (macro) level:

  • Health systems need to clearly define their purpose, goals, and values. Purpose, goals, and value statements are the foundations that guide the behaviours and actions of a health system’s agents and thus affect the function of the “health system as a whole”.

  • As the system emerges over time its purpose and values remained unchanged. What changed are its specific goals in light of newly identified needs.

All these examples have one thing in common, they all focus on the person/patient. This focus provides the necessary space required to allow for the essential complex adaptive work amongst all to realise best possible health experiences. This approach invariably results in:

  • More effective and efficient care delivery

  • Greater satisfaction of all involved in health care

  • Achieves equity

  • Makes the system more sustainable

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  1. 1.

    At the NEJM Catalyst event New Risk, New Business Models held in Boston, October 6, 2016, Dr Rushika Fernandopulle made these observations and drew the following observations: Attempts made by incumbent health plans and systems to address problems such as high costs and poor outcomes have not been wholly successful. Even new processes, rewards, technology, and culture changes meant to improve health care are still largely built for the old system. Despite lots of rhetoric, the real effort is almost always small and incremental. About 12 years ago, I realised that these small, incremental changes were not going to work. The problem is that our current health care system focuses on transactions. Last I checked, those don’t heal anyone. What heals people—the reason we all went into medicine—is relationships. To form those relationships, we must remove transactions, and to do that, we have to change everything. Change the payment model, change the delivery model, change the technology platform, maybe more importantly change the culture. (

  2. 2.

    For a step-by-step approach to developing this causal loop diagram see Sturmberg JP. Systems and complexity thinking in general practice. Part I—clinical application [31].

  3. 3.

  4. 4. Shape Up Somerville: Building and Sustaining a Healthy Community with Collective Impact Shape Up Somerville: NECN— Call to Revolution Mayor Joe Curtatone Speaks at White House for First Lady Obama’s Let’s Move Program 2.9.10


  1. Pellegrino E, Thomasma D (1981) A philosophical basis of medical practice: towards a philosophy and ethic of the healing professions. Oxford University Press, New York/Oxford

    Google Scholar 

  2. Leutz WN (1999) Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q 77(1):77–110

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  3. Sturmberg JP, O’Halloran DM, Martin CM (2010) People at the centre of complex adaptive health systems reform. Med J Aust 193(8):474–478

    PubMed  Google Scholar 

  4. Sturmberg JP, Martin CM, Moes M (2010) Health at the centre of health systems reform - How Philosophy Can Inform Policy. Perspect Biol Med 53(3):341–356

    CrossRef  PubMed  Google Scholar 

  5. Sturmberg JP, O’Halloran DM, Martin CM (2012) Understanding health system reform - a complex adaptive systems perspective. J Eval Clin Pract 18(1):202–208

    CrossRef  PubMed  Google Scholar 

  6. Valentijn PP, Schepman SM, Opheij W, Bruijnzeels MA (2013) Understanding integrated care: a comprehensive conceptual framework based on the integrative functions of primary care. Int J Integr Care 13:e010

    CrossRef  PubMed  PubMed Central  Google Scholar 

  7. Sturmberg JP, O’Halloran DM, Martin CM (2013) Health care reform - the need for a complex adaptive systems approach. In: Sturmberg JP, Martin CM (eds) Handbook of systems and complexity in health. Springer, New York, p 827–853

    CrossRef  Google Scholar 

  8. Sturmberg JP, Bennett JM, Picard M, Seely AJE (2015) The trajectory of life. Decreasing physiological network complexity through changing fractal patterns. Front Physiol 6:169

    Google Scholar 

  9. Antonovsky A (1993) Complexity, conflict, chaos, coherence, coercion and civility. Soc Sci Med 37(8):969–974

    CAS  CrossRef  PubMed  Google Scholar 

  10. Rutter M (1985) Resilience in the face of adversity. Protective factors and resistance to psychiatric disorder. Br J Psychiatry 147(6):598–611

    CAS  CrossRef  PubMed  Google Scholar 

  11. Reeve J, Lloyd-Williams M, Payne S, Dowrick C (2009) Towards a re-conceptualisation of the management of distress in palliative care patients: the self-integrity model. Prog Palliat Care 17(2):51–60

    CrossRef  Google Scholar 

  12. Launer J (2002) Narrative-based primary care: a practical guide. Radcliffe Medical Press Ltd, Oxford

    Google Scholar 

  13. Busby J, Purdy S, Hollingworth W (2015) A systematic review of the magnitude and cause of geographic variation in unplanned hospital admission rates and length of stay for ambulatory care sensitive conditions. BMC Health Serv Res 15:324

    CrossRef  PubMed  PubMed Central  Google Scholar 

  14. Hutchinson AF, Graco M, Rasekaba TM, Parikh S, Berlowitz DJ, Lim WK (2015) Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions. Health Qual Life Outcomes 13:69

    CrossRef  PubMed  PubMed Central  Google Scholar 

  15. Martin CM, Grady D, Deaconking S, McMahon C, Zarabzadeh A, O’Shea B (2011) Complex adaptive chronic care - typologies of patient journey: a case study. J Eval Clin Pract17(3): 520–524

    Google Scholar 

  16. Martin C, Biswas R, Joshi A, Sturmberg J (2011) Patient Journey Record Systems (PaJR): the development of a conceptual framework for a patient journey system. In: Biswas R, Martin CM (eds) User-driven healthcare and narrative medicine. IGI-Global, Hershy, PA, p 75–92

    CrossRef  Google Scholar 

  17. Martin CM (2014) Self-rated health: patterns in the journeys of patients with multi-morbidity and frailty. J Eval Clin Pract 20(6):1010–1016

    CrossRef  PubMed  Google Scholar 

  18. Mazzella F, Cacciatore F, Galizia G, Della-Morte D, Rossetti M, Abbruzzese R, et al (2010) Social support and long-term mortality in the elderly: role of comorbidity. Arch Gerontol Geriatr 51(3):323–328

    CrossRef  PubMed  Google Scholar 

  19. Lawton R, Taylor N, Clay-Williams R, Braithwaite J (2014) Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf 23:880–883

    CrossRef  PubMed  PubMed Central  Google Scholar 

  20. Lindberg C, Schneider M (2013) Combating infections at Maine Medical Center: insights into complexity-informed leadership from positive deviance. Leadership 9(2):229–253

    CrossRef  Google Scholar 

  21. Fulop L, Mark A (2013) Leading in healthcare - foregrounding context: the theory and practice of context - introduction to the special issue. Leadership 9(2):151–161

    CrossRef  Google Scholar 

  22. Seelos C, Mair J (2012) Innovation is not the holy grail. Stanf Soc Innov Rev 10(4):44–49

    Google Scholar 

  23. Ham C, Dixon A, Brooke B (2012) Transforming the delivery of health and social care: the case for fundamental change. King’s Fund, London

    Google Scholar 

  24. Heifetz R (1994) Leadership without easy answers. Harvard University Press, Cambridge, MA

    Google Scholar 

  25. Snowden DJ, Boone ME (2007) A leader’s framework for decision making. Harv Bus Rev 85 (11):69–76

    Google Scholar 

  26. Fulop L, Mark A (2013) Relational leadership, decision-making and the messiness of context in healthcare. Leadership 9(2):254–277

    CrossRef  Google Scholar 

  27. Sweet M (2011) Understanding miller: inside story [internet]. Published 28 March 2011

  28. Economos CD, Curtatone JA (2010) Shaping up Somerville: a community initiative in Massachusetts. Prev Med 50(Suppl 1):S97–S98

    CrossRef  PubMed  Google Scholar 

  29. Economos CD, Hyatt RR, Must A, Goldberg JP, Kuder J, Naumova EN, et al (2013) Shape Up Somerville two-year results: a community-based environmental change intervention sustains weight reduction in children. Prev Med 57(4):322–327

    CrossRef  PubMed  Google Scholar 

  30. Kurtz CF, Snowden DJ (2003) The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J 42(3):462–483

    CrossRef  Google Scholar 

  31. Sturmberg JP (2007) Systems and complexity thinking in general practice. part 1 - clinical application. Aust Fam Physician 36(3):170–173

    PubMed  Google Scholar 

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Sturmberg, J.P. (2018). Health System Redesign: Applying Complex Adaptive Systems Approaches. In: Health System Redesign. Springer, Cham.

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