Braithwaite et al.

BMC Medicine (2018) 16:63

[Link]

OPINION Open Access

When complexity science meets

implementation science: a theoretical and
empirical analysis of systems change
Jeffrey Braithwaite* , Kate Churruca, Janet C. Long, Louise A. Ellis and Jessica Herkes

Abstract
Background: Implementation science has a core aim – to get evidence into practice. Early in the evidence-based
medicine movement, this task was construed in linear terms, wherein the knowledge pipeline moved from
evidence created in the laboratory through to clinical trials and, finally, via new tests, drugs, equipment, or
procedures, into clinical practice. We now know that this straight-line thinking was naïve at best, and little more
than an idealization, with multiple fractures appearing in the pipeline.
Discussion: The knowledge pipeline derives from a mechanistic and linear approach to science, which, while
delivering huge advances in medicine over the last two centuries, is limited in its application to complex social
systems such as healthcare. Instead, complexity science, a theoretical approach to understanding interconnections
among agents and how they give rise to emergent, dynamic, systems-level behaviors, represents an increasingly
useful conceptual framework for change. Herein, we discuss what implementation science can learn from
complexity science, and tease out some of the properties of healthcare systems that enable or constrain the goals
we have for better, more effective, more evidence-based care. Two Australian examples, one largely top-down,
predicated on applying new standards across the country, and the other largely bottom-up, adopting medical
emergency teams in over 200 hospitals, provide empirical support for a complexity-informed approach to
implementation. The key lessons are that change can be stimulated in many ways, but a triggering mechanism is
needed, such as legislation or widespread stakeholder agreement; that feedback loops are crucial to continue
change momentum; that extended sweeps of time are involved, typically much longer than believed at the outset;
and that taking a systems-informed, complexity approach, having regard for existing networks and socio-technical
characteristics, is beneficial.
Conclusion: Construing healthcare as a complex adaptive system implies that getting evidence into routine
practice through a step-by-step model is not feasible. Complexity science forces us to consider the dynamic
properties of systems and the varying characteristics that are deeply enmeshed in social practices, whilst indicating
that multiple forces, variables, and influences must be factored into any change process, and that unpredictability
and uncertainty are normal properties of multi-part, intricate systems.
Keywords: Complexity science, Implementation science, Translation, Improvement, Change, Systems innovation,
Health and medical research, Take up, Speed, Culture

* Correspondence: [Link]@[Link]
Centre for Healthcare Resilience and Implementation Science, Australian
Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera
Road, North Ryde, NSW 2109, Australia

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License ([Link] which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
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([Link] applies to the data made available in this article, unless otherwise stated.
Braithwaite et al. BMC Medicine (2018) 16:63 Page 2 of 14

“As complex as things are today, everything will be of stages starting from the laboratory, into the randomized
more complex tomorrow.” trial environment, and then across real-world settings.
Such models implicitly assumed that those on the clin-
ical frontlines would naturally provide new types of care,
— K. Kelly in Out of Control: The New Biology of
such as novel pharmaceuticals, practices, or innovative
Machines, Social Systems and the Economic World [1]
technologies, based on the latest evidence, and all heavily
informed by upstream research. While various research
“One question … is whether the implementation of
pipeline models were proposed over the years, all were
radical organizational change in health care is
similar in that research evidence was assumed to advance
actually the core issue … there are many small-scale
in a rational, step-wise manner. One influential model, de-
improvements and experimental projects … thus the
scribed in the Cooksey report [3] (Fig. 1), was developed
primary issue is one of evaluation and spread.”
following a review of health research funding in the UK
examining the critical pathways to successful research
— L. Fitzgerald in Challenging Perspectives on
translation; it is often referred to, and equivalent models
Organizational Change in Health Care edited by L.
have been developed in other countries [4, 5].
Fitzgerald and A. M. McDermott [2]
However, the linear, rational way in which such a
model assumes that evidence is converted into practice
masks the complexity of the research–practice ecosys-
Background tem [6, 7]. It hides much of what is important in trying
In what now seems to us like the distant past, yet, in to accomplish evidence-based medicine, namely, that
reality, was merely a decade or so ago, medical scientists basic research is fundamentally risky and often does not
believed that the translation of research evidence into produce any useable breakthrough; that some ideas
practice followed a prescribed set of research steps, never even reach the prototype stage, let alone pre-
moving from test tube to needle, or bench to bedside. It clinical development; that even if developments progress
was common to apply the concept of a ‘pipeline’ as a to a trial, this may prove unsuccessful; that health ser-
heuristic for understanding research uptake. Adherents vices research is relatively poorly funded and thus imple-
to this view frequently diagrammed the process as a lin- menters often fall short of truly understanding how
ear one, conceptualizing interventions through a series socio-professional systems work in practice; and that the

Fig. 1 Example of a causal linear approach for the translation of health research into practice. Source: Cooksey [3]. Use of this image is supported
by an Open Government License ([Link]
Braithwaite et al. BMC Medicine (2018) 16:63 Page 3 of 14

‘translation gaps’ (more like chasms) between research circumstances as people navigate across time in
findings and their use in practice often cannot be messy ecosystems.
bridged [8–10]. Von Bertalanffy’s ideas date decades earlier, and his
This traditional manner of thinking about research development of ‘General System Theory’ laid the
pathways was founded on a Newtonian-style, clockwork platform for much of the later work. He, in turn, drew
universe paradigm, representing a mechanistic and re- on even earlier sociological, mathematical, and biological
ductionist view of the way the world works, dominated research and theories, and by approximately 1946 he
by the randomized clinical trial and precision measure- had assembled General System Theory, applying univer-
ment. In reality, when we deal with non-mechanical hu- sal principles and espousing the ontological underpin-
man systems, this view has serious limitations [11]. To nings for the interactive and dynamic nature of social
extend the metaphor, in contrast to a Newtonian view, organization and structuring [14, 16].
the health system is more quantum mechanical than Andrew Van de Ven’s work built on this systems
classically clockwork, and is characterized by uncer- approach through the 1990s, culminating in his book
tainty, emergence, and embedded unpredictability. The Innovation Journey [15], which proved timely and
Participants exert effects on the system; sometimes, the useful for those interested in translational research pro-
system appears wave-like (akin to group behaviors), cesses. An organizational theorist, he too distinguished
sometimes particle-like (with individual agents’ efforts between linear conceptualizations and more unpredict-
having influence), and it changes once measured or ob- able, iterative approaches, but made a further distinction
served, because measurers and observers are entangled between the two world views. When speaking about
within the system and each other. The health system is innovation, he argued that attention must be paid to
probabilistic and stochastic rather than deterministic fluidity, messiness, and even chaotic tendencies. Van de
and causal. Ven noted, through a series of case studies, that
innovation often manifests not progressively in a step-
Shifting the paradigm by-step manner, but recursively, and always diverging
Some 10 to 15 years ago, several thinkers began to from aspired-to pathways. He encapsulated this duality
realize the limitations inherent in the pipeline idea [12] by showing the implicit mechanistic assumptions made
as it became increasingly obvious that getting evidence in the literature, in stark contrast with what hke actually
into practice was much harder than earlier proponents saw when he researched and observed innovative prac-
believed. This recognition came from the knowledge and tices (Table 1).
understanding of human systems that had been accumu- For Van de Ven and his intellectual successors, the tra-
lating in sociology, ecology, and evolutionary biology jectories to an innovative outcome always have several
ever since the 1940s, and with antecedents even earlier, variations, multiple pathways, unanticipated processes
which we can loosely call ‘systems thinking’. and results, and exhibit conflict between stakeholders.
The systems view is based on several fundamental People flex and adjust, accommodating to local condi-
ideas, essentially, that all systems are composed of a set tions, and always deviate from idealized pathways.
of seemingly discrete but actually interdependent com- Innovation processes for Van de Ven are neither stable
ponents, defined not just by their inter-relations but by and predictable nor stochastic and chaotic. Being an in-
the permeable and shifting boundaries between them. novator implies working with inherent unpredictability,
The components (people, technology, artefacts, equip- sometimes with random effects, and dealing with the
ment) are combined haphazardly and in unexpected multiplicity of internal and external forces that impinge
ways, aggregating to be more than the sum of their on and are intrinsic to the journey. Sometimes, innova-
parts, and are characterized by eddying, recurring pat- tors need to run with the pack, and at other timess do
terns of behavior. Key moments in the path of articulat- so in opposition. Persistence in the face of setbacks and
ing a systems view of the world arose through the work an ability to work with, or simply just understand,
of many theorists, but management scientist Peter multiple agents who inhabit indistinct, orthogonal, or
Checkland [13], biologist Ludwig von Bertalanffy [14], oppositional cultures and subcultures, facing sometimes
and organizational theorist Andrew Van de Ven [15] can destructive and sometimes constructive politics, and
be used as proxy exemplars. experiencing periods of inactivity, are all features of the
Checkland’s pioneering work [13], beginning in the innovation journey.
1960s, was encapsulated under the title ‘soft systems
methodology’. This approach differentiated between hard Bringing the systems view together
systems, represented by relatively rigid techniques, tech- From 2004, this rich theorizing and new-fashioned con-
nology, artefacts, and equipment, and soft systems, which ceptualizing of the ontology of improvement pathways
involve the learning that occurs in fuzzy, ill-defined began to be applied more concertedly to healthcare.
Braithwaite et al. BMC Medicine (2018) 16:63 Page 4 of 14

Table 1 Assumptions and observations about core innovation concepts

Concept Linear causal thinking Systems thinking
Ideas One invention, operationalized Reinvention, proliferation, reimplementation, discarding, and
termination
Innovator(s) An entrepreneur with a fixed set of full-time people over time Many entrepreneurs and other players, sometimes on-track
and sometimes distracted, fluidly engaging and disengaging
over time in a variety of roles
Transaction A defined network of people or firms working out details of an Expanding, contracting, and flexing networks of partisan
idea between themselves stakeholders who converge and diverge on ideas
Context The environment provides opportunities and constraints on The innovation process is captured by political and cultural
the innovation process features, and creates opponents or is constrained by multiple
enacted environments
Process Simple, orderly, cumulative sequences of stages or phases Multiple messy, imprecise journeys; many divergent, parallel
and convergent paths; some related, others not
Outcomes Final result predictable; a stable new order comes into being Final result indeterminate; many in-process perturbations,
assessments and spinoffs; integration of any new order with
old orders
Source: Modified from Van de Ven et al. [15]

Many of these ideas converged in Greenhalgh’s work on external or outer context. For ease of access and read-
the diffusion of innovation, where she and her colleagues ability, we have streamlined this model by rationalizing
brought together disparate research in an influential the number of variables that Greenhalgh et al. [12] stip-
paper that provided an extended systems model articu- ulated in their original work. Of course, all models are
lating the intricacies, problematics, and minutiae of get- simplifications of reality and even one that acknowledges
ting evidence into practice (Fig. 2) [12]. The Greenhalgh a very large number of variables is, nevertheless, merely
model suggested four pivotal systems factors important a model that reduces real-world complexity for the pur-
for innovation, namely the innovation itself, and its char- poses of explication.
acteristics; the system’s propensity, or its readiness, for This is not to deny that there are, at the broadest
change; the journey or implementation process; and the levels, iterative roadmaps from bench to bedside or test

Fig. 2 Conceptual model – determinants of diffusion, dissemination, and implementation of innovations in health services. Source: Modified from
Greenhalgh et al. [12]. Written permission granted by Wiley Global Permissions
Braithwaite et al. BMC Medicine (2018) 16:63 Page 5 of 14

tube to needle. However, this assessment does illuminate Complexity science challenges conventional wisdom
the reality that there are many components, moving and an unduly straight-line approach to implementation
parts, and shifting relationships, and that innovative on a number of fronts. Traditionally, people have studied
journeys are much more convoluted, imprecise, uncertain, parts of a system (the people, the intervention, the out-
ambiguous, and deceptive than the pipeline proponents comes) as distinct variables, assuming the influences on
realized or hoped for. Social science had been waiting in one another to be straightforward [25], or at least know-
the wings, eager to point this out, and have the mechanis- able. These effects were conceived as additive, where the
tic pipeline view excised. It brings to mind the English sum of the parts equaled the whole and a predictable
poet, David Whyte, who aphoristically said, “Stop trying to relationship existed; that is, causes were identifiable
change reality by attempting to eliminate complexity” [17], because they preceded effects, and led to them. In
and Abdus Salam, the Pakistani theoretical physicist and designing interventions, people in this mode have aimed
Nobel Prize winner, who once remarked, “From time im- for reduction and control, removing the influence of, or
memorial, man has desired to comprehend the complexity controlling, ‘extraneous’ or ‘confounding’ variables [26].
of nature in terms of as few elementary concepts as pos- Researchers and implementers then inferred the ability
sible” [18]. Yet, more mechanistic, simplified views of the to generalize findings derived from this approach across
world cannot wish away its complexity. contexts. Thus, an effect observed through well-controlled
That said, there are some today who still persistently experimentation in one environment would be assumed
hold a traditional pipeline view, even in the face of ex- to occur similarly in other situations; this may have
perience with its shortcomings. At bedrock, this most worked in some cases, but by no means always.
likely has something to do with the architecture of the In contradistinction, in complexity science, while the
human mind, which often sees things in cause-and- components of a system, namely the agents and their ar-
effect terms [11, 19]. The brain has evolved to compose tefacts, are important, they are often secondary to the
a narrative, linear account of events that unfold with a relationships between these components [27]. In such
past–present–future representation of how things work systems, agents communicate and learn from each other
[11, 19]; this forms part of the executive function of the and from their environment, and adjust their behavior
brain responsible for planning, organizing, and reasoning accordingly. However, there are many cross-cutting
[20]. Of course, the mind is also capable of out-of-the- interconnections and influences. As such, the system is
box creative thinking, but straight-line rationalizing fre- best described as a CAS, meaning that it has the capability
quently trumps other ways of imagining how the world to self-organize, accommodate to behaviors and events,
works. learn from experience, and dynamically evolve [28], but
not necessarily in ways anyone can forecast with any
Complex Adaptive Systems (CAS) theory – raising degree of confidence.
the bar in the challenge to linearity The self-organizing, iterative, reverberating interac-
When we talk about the world being more complex than tions among agents, which in the healthcare CAS in-
we typically imagine it to be, we do not just mean that it cludes stakeholder groups such as doctors, allied health,
is complicated, or layered, or socially dense, or some- patients, nurses, managers, and policymakers, as well as
times confusing. We do not mean, either, that it is many other subgroups, give rise to unpredictability and
merely unpredictable and varied, although it is certainly nonlinearity, with causes and effects often disconnected
all of these things. We are also heralding the science of or disproportional to one another [19, 25]. CASs are dis-
complex systems, which has developed, in part, out of tributed in space and behave dynamically across time,
systems theory, as a multi-disciplinary take on under- with idiosyncratic interactions among agents at the local
standing many facets of the world (see Glossary of level determining the context, and the present and fu-
terms; Table 2). ture behaviors of the system [24]. Through the interac-
Complexity theory can be applied at multiple scales, tions among the system’s components, global system
from the very smallest, ranging from quantum foam to patterns emerge and new factors (e.g., technology, pol-
quarks, to the minutiae of the chemical and biological icy, novel relationships, practices) eventuate.
underpinnings of matter, to the behavior of molecules These patterns are influenced by feedback loops,
and cells, up to the macro interactions of humans, their where different system inputs at different points in time
groups, and even entire civilizations [21]. Complexity perpetuate their own outputs, either dampening or en-
science has more recently been utilized in healthcare in hancing them. Feedback helps to explain how responses
order to apprehend, for example, the management, to interventions, which might be positive at first, are
safety, and organization of clinical services [22, 23], as often not sustained. The relatively loosely or tightly
well as the implementation of interventions and the coupled interconnections between agents within a CAS,
translation of evidence into practice [24]. and their changeability over time, suggest there is much
Braithwaite et al. BMC Medicine (2018) 16:63 Page 6 of 14

Table 2 Glossary of terms

Glossary of terms
Adaptation The capacity to adjust to internal and external circumstances; usually thought of in terms of modifying behaviors over
time
Agents The individual components of a complex system – typically, individuals, whose capacity for sense-making means they can
learn and adapt their behaviors across time, or artefacts
Complex Adaptive A dynamic, self-similar collectivity of interacting, adaptive agents and their artefacts
System
Complexity The behavior embedded in highly composite systems or models of systems with large numbers of interacting
components (e.g., agents, artefacts and groups); their ongoing, repeated interactions create local rules and rich, collective
behaviors
Culture The sum of the shared values, attitudes, and beliefs across part of or the whole of an organization (e.g., across the division
of medicine, or an entire hospital or health service)
Emergence Behaviors that are built from smaller or simpler entities, the characteristics or properties of which arise through the
interactions of those smaller or simpler entities; the larger entities are one level up in scale, and manifest as social
structures, patterns, or properties
Feedback loop A recursive mechanism creating reciprocal behaviors that reverberate back in on themselves; a positive (self-reinforcing)
feedback loop increases the rate of change of a factor, creating more of its own output; in a negative (self-correcting)
feedback loop, the output responses dampen the change or modulate its direction
Implementation science The processes of translating research into practice, understanding what influences translational outcomes, and evaluating
the adoption of interventions
Network An interlocking web of relationships or connections at varying levels of scale in a system; the agents or artefacts are the
nodes and the relationships between them are lines or vectors, which together describe the structure of the interactions
of the network’s membership
Path dependence Current events and circumstances are influenced, and can be determined, by prior events and circumstances, harking back
to the origins of the entity or system; path dependence underpins the point that ‘history matters’
Perturbation An internal or external disruption or unexpected event that affects normal patterned behaviors, structures or processes;
often thought of as an external disturbance or interruption to the current state-of-affairs
Self-organization The way in which agents interact to coordinate their own circumstances, workplaces, processes and procedures, such that
they order their work and they autonomously, or semi-autonomously, organize their localized behavior; this can occur
passively or actively
Sensemaking Methods by which individuals figure out what is going on around them; a typically social process among agents in which
they come to a shared meaning of their experience, and is necessary for action in the face of ambiguity or uncertainty
Social network A set of people who have relationships, communications, ties, or interactions that connect them
System dynamics An analytical modelling methodology used for problem solving, which combines qualitative and quantitative data and
identifies the fundamental elements of a system, and how they influence one another over time
Tipping point A critical point in a system in which a kind of radical, potentially irreversible, change may occur, resulting in a different
state of system behavior, which can settle into a new equilibrium

propensity for unintended consequences of an interven- evidence into practice, but rather comprises diverse per-
tion in addition to the improvements agents hope for spectives, frameworks, and methods. However, broadly,
[29]. Borrowing from Gould and Eldridge’s famous dis- implementation science is characterized by three aims,
tinction in evolutionary biology [30], health system pro- namely (1) to describe the process of translating research
gress in such circumstances resonates much more with into practice (process models), (2) to understand what in-
the idea of punctuated equilibrium than that of morpho- fluences implementation outcomes (determinant frame-
logic gradualism. works, classic theories, implementation theories), and (3) to
evaluate the implementation of interventions (evaluation
Enter implementation science frameworks) [31].
More recently, the efforts to study methods and mobilize The two sciences of complexity and implementation need
knowledge, designed to enhance the ways in which we not be mutually exclusive, though they have been largely
acquire and use evidence in healthcare, have been seen and treated as such. Nevertheless, some of what is
termed ‘implementation science’. For convenience, we published under the umbrella of implementation science is
can date this idea from the first issue of Implementation certainly antithetical to complexity science, drawing as it
Science in 2006, although some scholars had been work- does from the linear, reductionist paradigms. Table 3 pro-
ing on the development of this field before then. Imple- vides a brief comparison of the sciences of complexity and
mentation science is not a unified approach to getting implementation, as well as how they might be fused.
Braithwaite et al. BMC Medicine (2018) 16:63 Page 7 of 14

Table 3 Comparison of some key characteristics of implementation science and complexity science and their integration
Features Implementation science Complexity science Complexity science and
implementation science
Task The task is specific: getting The task is context dependent; Tailored solutions and iterative
evidence into clinical practice in properties of complexity apply to processes
an understandable way biology, ecology, physics,
computer science, human social
systems
Theoretical assumptions Heterogeneous and diverse – Homogenous – core Different theories, frameworks,
numerous theories, frameworks, assumptions of complexity and models require an
and models science are characterized by understanding of complexity
‘universality’ (i.e., they apply features such as unpredictability,
across all complex systems) uncertainty, emergence,
interconnection
The intervention To be standardized to permit To be adapted to meet needs Factoring in complex
generalizability interventions and complex
settings
The context Full of confounders, a ‘problem’ An intrinsic part of a complex For improvement to be realized,
to be solved for successful system; a dynamic environment the context must be re-etched or
implementation that must be factored in for any re-inscribed such that its culture,
intervention to be successfully politics, and characteristics are
taken up altered
Historical underpinnings Evidence-based practice Systems theory, chaos theory; More sophisticated change
movement, statistics, and the emanating from diverse scientific models can be encouraged to
scientific method disciplines arise over time
Aims within health services research - Describing or guiding the - Description of complex system - Ensure that turning evidence
process of translating research • Understanding context into practice is accomplished
into practice (process models) • Relationships among agents without too many unintended
- Understanding or explaining • Dynamics negative consequences;
what influences • How rules and governance improvement might be
implementation outcomes structures emerge, i.e., self- sustained, potentially through
(determinant frameworks, organization the adaptation of the
classic theories, implementation - For prediction rather than intervention to different
theories) implementation settings
- Evaluating implementation - Implementation is not merely
(evaluation frameworks) based on effective planning but
anticipation of a range of
possible outcomes
Tools and methods Randomized controlled trials, Causal loop diagrams, system Realist evaluation, long-term case
behavior change interventions, dynamics modelling, network study, participatory research,
step-wedge designs articulations stakeholder analysis, systems
mapping, social network analysis
Sources: Authors’ conceptualizations and May et al. [24]; Braithwaite et al. [7]; Rapport et al. [65]; Hawe et al. [32]

Despite their differences, the two theoretical para- already teeming with activity and relationships, know-
digms can be used together to the benefit of both theory ledge uptake is rarely simple or straightforward, and has
building and healthcare practice and systems improve- to find a place in an intricate, pre-existing milieu.
ment. The complexity lens can help illuminate the scope Going further, spread is closely related to uptake. The
of the implementation problem to be tackled and the patterns of interaction between agents and their envir-
dynamics of change and inertia. The translation of evi- onment are locally specific, and although they share fea-
dence into new clinical or organizational practices does tures with other CASs, they also exhibit remarkable
not unfold in a static and controlled environment await- variation from one site to the next. The notion, then,
ing the attention of top-down change agents; it takes that a new practice can be adopted equally well and in
place in settings comprised of diverse actors with varying the same manner across a whole health system, is
levels of interest, capacity, and time, interacting in ways untenable. Thus, standardization of an intervention, and
that are culturally deeply sedimented, and have often assuming its generalizability, can be the downfall of suc-
solidified [32, 33]. In other words, the complex patterns cessful implementation [34].
by which healthcare is delivered, and the enmeshed so- However, implementation scientists, or at least those
cial structures inherent within the system, are already working within implementation science with pluralistic
established and entrenched. In such a networked, at conceptualizations of the world, have not been standing
times tightly and at others loosely coupled ecosystem, still. The need to factor in context is being increasingly
Braithwaite et al. BMC Medicine (2018) 16:63 Page 8 of 14

recognized by scholars in implementation science, as is be the iterative and responsive, more ecology-aware,
the identification of barriers and facilitators to an inter- social science-informed approaches such as those envis-
vention [35]. For example, the Promoting Action on aged by longer term realist designs or process evaluation
Research Implementation in Health Services formula of implementation efforts [32, 42].
[36] sees successful implementation as a function of the Despite the potential utility in harnessing complexity
explicit interrelations among evidence, context, and fa- science for implementation, until now, not much con-
cilitation. Nevertheless, these contextual characteristics joining of the two, either theoretically or empirically, has
of the environment are often viewed as ‘confounders’ in occurred. There have been intermittent examples of
implementation research, rather than the normal condi- using a complex systems framework to inform clinical
tions of practice in healthcare. Complexity science, in transformation, as when Best et al. [43] applied com-
highlighting the dynamic properties of every CAS and the plexity thinking in the implementation of new clinical
local nature of each system’s culture, suggests that what guidelines in British Columbia, Canada. They noted that
operates as a ‘barrier’ to implementation in one site may the implementation of the guidelines required the ability
not do so in another, and could even be facilitative [24]. to tailor system-level recommendations to local context.
In another promising turn, there have been more recent
Informing implementation with complexity attempts to explicitly challenge the pipeline view of
In complexity-informed approaches to implementation it knowledge translation, with Kitson et al. [40] undergoing
is not enough to leverage facilitators or eliminate bar- an iterative process to develop a complexity-informed
riers; the focus of implementation shifts from the fidelity model that highlighted the connections between phases
of the intervention to its effective adaptation [37, 38]. previously conceptualized as discrete such as problem
Thus, Hawe et al. [34] argue that, rather than standard- identification and knowledge synthesis. This model (Fig. 3)
izing aspects of an intervention, despite some essential in essence highlights the key issues to be considered,
functions being replicable, the form of an intervention including the distinctions and connections between know-
should be varied as required by context [39]. This type ledge users and knowledge generators, the importance of
of CAS-oriented approach is particularly important arriving at good definitions for the gaps, and co-producing
when attempting to scale-up or spread interventions new knowledge and contextualizing it, as well as imple-
previously found to be effective in one, or a limited mentation and evaluation.
number of sites, to the whole system. Improvement
structures may thus involve tailoring to context and har-
nessing the self-organizing and sense-making capacities
of local agents [38]. Indeed, working with bottom-up
local stakeholders is paramount to adapting an interven-
tion to their practices, facilitating ways to get them on-
board with the intervention, in piloting it, in reflecting
on progress amongst stakeholders, and in providing
feedback to participants to help them embrace implemen-
tation iteratively over time. In such a messy, complex set
of circumstances, it makes less and less sense to think of
‘knowledge producers’ as conceptually distinct from
‘knowledge users’ [40] when indeed they are inter-related.
Chambers et al. [41] suggest that a further consider-
ation is the sustainability of an intervention. Sustainable
change requires the ongoing adaptation of an interven-
tion to multilevel contexts, with expectations for lasting
improvement rather than diminishing outcomes over
time. In this regard, implementation in the hands of
complexity theorists is increasingly recognized as an it-
erative and recursive, long-term process rather than a
linear one [35]. Complexity science thereby encourages
not only attention to the context of an intervention, but
also to the interactions between elements and the conse- Fig. 3 Process of developing a model of knowledge translation
quences of this intervention for the system. The imple- aligned to complexity science. Source: Modified from Kitson et al.
[40]. Use of this image is supported by a Creative Commons
mentation method of choice will not necessarily be the
License [Link]
randomized clinical trial or experimental design, but will
Braithwaite et al. BMC Medicine (2018) 16:63 Page 9 of 14

That said, a recent systematic review by Brainard et al. adoption were identified as the entrenched medical and
[29] found that health interventions using complexity management hierarchies, and an onerous bureaucracy.
science approaches have done so inconsistently, for ex- Perhaps more significantly, there were strongly deter-
ample, often not incorporating an evaluation component ministic path dependencies, represented by a pervasive
or failing to analyze the potential, unintended conse- belief in medical culture that patients were ‘owned’ by
quences of the intervention. Nevertheless, this recent their admitting doctor, a belief that clouded who was au-
work has suggested the value of complexity science in thorized to treat and where accountability for patients
creating large-scale system transformation, including lay. In Liverpool, innovation was more accepted, medical
sensitizing stakeholders to the natural properties of autonomy less jealously guarded, and there was a culture
CAS that might then be leveraged by emphasizing of readiness for experimentation and change.
distributed leadership, networks, sense-making, and The notion of the MET began to be taken up in other
feedback loops [38, 42, 44]. countries without active implementation mechanisms.
Thus, thinking is altering, at least amongst some lead- Through deceptively simple knowledge dissemination
ing theorists and researchers, and we are now more means, such as articles in low-impact publications or
advanced in understanding systems change, with new conference presentations, and clinical networks and in-
models replacing the pipeline approach. Having estab- formal discussions, clinicians assessed their needs and
lished the juxtaposition of complexity and implementa- adopted METs, tentatively at first, into their own context
tion, we now examine how some of these ideas have [49]. This highlights that, while an implementation plan
been leveraged to accomplish large-scale system trans- is typically necessary for system-wide change, bottom-
formations in Australia, exploiting the combined up, knowledge dissemination approaches can facilitate
complexity–implementation paradigm. attitude change. That is, interconnected clinicians com-
municate locally and across the boundaries of their sys-
Case 1: Rapid response systems and the New South Wales tems, influencing one another in their own and other
‘Between the Flags’ (BtF) program environments, and self-organizing their practices in
Since the 1980s, there has been an increasing focus on novel ways based on this new knowledge. This type of
patient safety and quality of care in hospitals inter- on-the-ground interactivity, whereby clinicians felt own-
nationally, as well as in Australia. Many initiatives have ership of the incremental changes rather than having it
been designed and conducted, but there is limited evi- imposed on them, made possible the eventual system-
dence to show that systems-level improvement has been wide transformation.
achieved [45]. One notable exception has been the im- The tipping point for dissemination of many large-
plementation of rapid response systems (RRSs), in which scale, system-wide changes has been in the form of a
specialized teams attend to inpatients whose deteriorat- perturbation to the system, such as the SARS epidemic
ing condition has been identified through reference to a in Canada or the tragic death of teenager Vanessa An-
set of defined criteria. RRSs have had a significant im- derson in NSW, Australia [50]. This latter case, deemed
pact on patient safety, with evidence that they have re- a preventable death caused by failure to recognize the
duced inpatient mortality and cardiac arrests by about teenager’s deteriorating condition, led to the BtF pro-
one-third [46, 47]. Yet, RRSs illustrate that even a rela- gram, which flipped the bottom-up approach of previous
tively simple and intuitively sound intervention can MET implementations into a whole-of-system approach
struggle to be adopted into the CAS of healthcare, where with concerted support from multiple sectors, including
history, path-dependence, and context, especially social government [51].
influences, can have substantial effects. BtF alludes to the Australian Surf Life Saving model
RRSs were a bottom-up initiative, coming from self- that offers surveillance of bathers on popular surf bea-
organizing clinicians who recognized that the deterior- ches, who swim between two yellow and red flags,
ation of a patient’s condition could easily go undetected planted conspicuously in the sand. Surf Life Saving
until it was too late to reverse. In their chapter outlining Australia estimate that they rescue 35 swimmers under
the history of the RRS in Australia, Braithwaite et al. threat of drowning and intervene in 913 other cases per
[48] described the strong influence of context on the hour on a typical summer’s day using this simple model.
adoption of this intervention. Attempts in the early The BtF program used the imagery of a safe zone to re-
1980s to introduce a Medical Emergency Team (MET), design and standardize vital sign charts across the hos-
the precursor of RRSs, failed in a large London teaching pital system [52], with upper and lower unsafe limits
hospital due to inertia and unconcealed opposition, but reflecting the colors of the flags (yellow as early deterior-
succeeded in a smaller, more recently established teach- ation warning sign, red as late). Vital sign readings that
ing hospital in Liverpool, New South Wales (NSW), were in the yellow zones triggered an urgent clinical
Australia. Barriers and confounders of the London review and the red triggered intervention by the
Braithwaite et al. BMC Medicine (2018) 16:63 Page 10 of 14

specialized MET. The work was led by the Clinical Ex- solutions prior to the roll out of such a large-scale
cellence Commission, an agency set up to oversee qual- intervention.
ity and safety across NSW healthcare.
For a linear thinker, this highly effective intervention Case 2: New nation-wide safety and quality standards
would seem easy to implement with predictable, positive In 2013, systems-level reform of the Australian accredit-
outcomes. However, the issue is not the relative simpli- ation model occurred with the implementation of the
city of the model of monitoring a patient’s vital signs Australian Health Service Safety and Quality Accredit-
with a standardized form and the use of a MET inter- ation Scheme. A critical component of the scheme, over-
vention to ‘rescue’ them when straying into the unsafe seen by the Australian Commission on Safety and Quality
yellow or red zones, but rather the complexity of the in Health Care (ACSQHC), has been the development
system into which the intervention is being introduced. and application of new National Safety and Quality Health
BtF was implemented into NSW’s 225 public hospitals Service Standards (NSQHSS). The development of the 10
in January 2010. Many had already adopted RRS-style standards represented an important element in the safety
models in idiosyncratic ways. For its successful introduc- and quality of care architecture of the health system. The
tion, the Clinical Excellence Commission recognized the standards cover areas including governance arrangements,
complexity of the system, including the independence partnerships with consumers, and eight key clinical areas
and interdependence of agents, the presence of positive of health service operation (Box 1).
and negative social influences, and the generation of Each standard has a set of criteria, and for each criter-
possible adverse knock-on effects. Accordingly, the pro- ion, a series of actions are required to be fulfilled. To
gram had five elements, namely governance, standard achieve accreditation status, all core actions for health ser-
calling criteria (the red and yellow flags), a two-tiered vices must be demonstrated. The work has drawn inter-
RRS in each facility, an associated education program, national interest and is informing efforts to improve the
and an evaluation plan. Governance mechanisms sup- safety and quality of healthcare in other countries [54].
ported by well-staffed and supportive advisory boards, The Australian Health Service Safety and Quality
alongside a State-wide policy directive, held hospitals to Accreditation Scheme has been enacted with an appreci-
an implementation schedule with scope for local flexibil- ation of the CAS features of healthcare, and the imple-
ity and promulgated clearly defined roles and expecta- mentation process was dynamically modified in response
tions. The standard calling criteria were incorporated to the multifarious and interlinked institutions, groups,
into the new, mandatory NSW standard observation and structural arrangements that can hinder or facilitate
charts with a simple track-and-trigger design. implementation, and must ultimately adopt the model.
The two-tiered RRS response was developed to pre- International experience shows that the inherent com-
vent the problem of false positives that could overwhelm plexity of healthcare and in-built resistance, regardless
the system, as well as false negatives that would result in of country, can be an impediment to adoption of such
failure to rescue [53]. Both types of errors could under- systems-level reforms [55–58].
mine the credibility of the program and lead to poor
clinical compliance on the wards. BtF designers also Box 1: The 10 National Safety and Quality Health
understood the challenge of embedded social influences Service Standards
such as medical hierarchies and clinical tribalism [48].
The program diffused authority for intervention from 1. Governance for safety and quality in health service
medical consultants to any health professional detecting organizations
a patient outside the flags. 2. Partnering with consumers
Following the extensive preparation period, uptake 3. Preventing and controlling healthcare associated infections
was rapid. Clinician fears of ‘extra paperwork’ were 4. Medication safety
shown to be unfounded and the empowerment of nurs-
5. Patient identification and procedure matching
ing and junior medical staff to initiate a rescue rein-
6. Clinical handover
forced its utility. Evaluation data, as it was collected,
showed consistent falls in cardiac arrest and mortality 7. Blood and blood products
rates (cardiac arrest by 42%; P < 0.05) and the rapid re- 8. Preventing and managing pressure injuries
sponse rate increased by 135.9% (P < 0.05) [53]. 9. Recognizing and responding to clinical deterioration in acute
Thus, BtF showed that successful implementation re- healthcare
quires an understanding of the complex system into 10. Preventing falls and harm from falls
which even ‘simple’ interventions are being introduced. Source: Australian Commission on Safety and Quality in Health
CAS theory can help to unpack the multi-dimensional
Care [59].
contextual issues and address them with multifaceted
Braithwaite et al. BMC Medicine (2018) 16:63 Page 11 of 14

To respond to this challenging environment, the the initiative has been seen to mobilize expectations,
ACSQHC undertook extensive consultation activities integrate roles and responsibilities, and promote trans-
with the aim of determining appropriate methods of util- parency [54].
izing existing government legislative powers to support From the outset, two potential risks to the credibility of
the reform measures, to align the views and actions of and satisfaction with the scheme at the health system level
diverse groups, and to foster distributed leadership were raised, namely the application of the NSQHSS across
across reform elements [59–61]. In total, the ACSQHC varied settings and the reliability of assessments by different
arranged 227 separate consultation activities involving accrediting agencies. The application of the NSQHSS
over 1000 stakeholders spanning the breadth of the Aus- across settings was discussed in the consultations as a point
tralian health system. The perceived importance of these of credibility – that the same expectations would be applied
activities for maximizing the effectiveness of the scheme to different health services, in different settings, was consid-
reinforces the fundamental role of continued stakeholder ered vital to the government’s interests in equity [54].
engagement as a necessary facilitator of national reform Four strategies to facilitate implementation, to reinforce
[54]. The need for effective stakeholder engagement has the potential benefits, and to overcome the substantial
also been identified in relation to other systems-level challenges facing the scheme emerged (Fig. 4). The wide-
healthcare reforms internationally [62, 63]. The ACSQHC spread ACSQHC consultation activities were seen to
continues to undertake consultation with health services facilitate implementation by providing a common plat-
to facilitate effective implementation of the scheme and form for knowledge transfer, encouraging widespread
further revisions have been made to the standards over stakeholder engagement. At those meetings, high-quality,
time (in 2016 and again in 2017), assuring their continued accessible educational activities and materials were pro-
relevance [59–61]. vided. Feedback loops in the form of regular review of the
Despite the nature of the standards’ implementation as program and updates to the system using progress data
seemingly a top-down, government-sponsored, homoge- helped maintain momentum.
neous model, NSQHSS have been well received by the
system due to the clinical focus of most of the standards. Discussion
This was considered crucial for increasing the engage- Pipeline models sprang initially from those adhering to a
ment of health professionals and board members in linear worldview of the path from knowledge creation,
health and quality improvement activities [54]. Partici- through knowledge products, to knowledge use. The
pants proposed that the NSQHSS provided, for the first task was to get evidence into practice, and this was seen
time, a clearly evidenced-oriented, coherent, and inte- by many as a simple, staged activity, following recipe-
grated national framework. The scheme separated and style models such as the one expressed by Cooksey [3].
clarified responsibilities of different actors for accredit- In the minds of many scholars and practitioners, includ-
ation standards development, surveying processes and ing some who self-define as implementation scientists,
decisions, and regulation and policy matters. As a result, the process of bench to bedside has, by and large, continued

Fig. 4 Strategies facilitating implementation. Source: Greenfield et al. [54] Permission granted by John Wiley and Sons for use of this image.
License number: 4236860320684
Braithwaite et al. BMC Medicine (2018) 16:63 Page 12 of 14

to be conceptualized in a largely mechanical frame, although exemplars to empirically illuminate the interface of the two
some researchers and theorists have introduced complexity paradigms (Table 4). These case studies show that successful
ideas to it [7, 40, 64]. Complexity science offers a radically systems change can take varied forms and that the imple-
different set of considerations to those interested in systems mentation sequence can differ depending on circumstance
change. As a paradigm, it denies over-simplification, and is and needs. Thus, a hybrid of factors drawn from implemen-
conceptually transformative, adding a much richer set of un- tation science and complexity science help explain how sys-
derstandings to the task of systems improvement. tems change occurred in these two case exemplars.
The two traditions of implementation science and The key is to harness such understanding to
complexity science can be drawn together, and culmin- strengthen progress with other multifaceted health sys-
ate in more textured, multi-dimensional, complexity- tems interventions. Based on these examples, the por-
informed models. Paradigm-shifting exemplars that have tents are for future change agents to conjoin complexity
achieved this include those offered by Greenhalgh et al. science and implementation science approaches for the
[12] on innovation (Fig. 2) and Kitson et al. [40] on benefit of systems-level change.
knowledge transfer (Fig. 3).
The RRS case was bottom-up followed by top-down; the Conclusion
accreditation case was top-down but with middle-out and Notwithstanding this analysis and these case exemplars, we
bottom-up responses. Whether top-down, middle-out, or conclude with a word of warning. Complexity thinking adds
bottom-up, these Australian case exemplars show how a real-world, multidimensional appreciation of the system
complexity science attributes (emerging ideas, iterative ap- and its density and dynamics, but it does not make it easier
proaches, feedback mechanisms, inter-dependencies, build- to effect change; in fact, the opposite is true. We can no lon-
ing momentum over time, dynamic communication with ger assume to solve health systems issues by pretending or
multiple stakeholders, systems perturbation) can be fac- conspiring to imagine that they have Newtonian properties,
tored into change programs. Both cases involved extensive and pipeline models should be seen for what they always
coalition building over multiple years in order to reach a were – idealistic, normative renderings of the world. Even
tipping point. We provide a synthesis of what we have though this makes our ambitions to improve healthcare in-
learned from this theoretical analysis of implementation furiatingly more difficult, we must grapple with the world we
science and complexity science by using the case actually inhabit, not the one we wish we did.

Table 4 Case study comparisons – exemplifications of implementation science and complexity science paradigms
Selected implementation or Case 1: Rapid response systems’ adoption and spread Case 2: Introduction of national quality standards
complexity characteristic
Overarching strategy and Bottom-up followed by top-down implementation, with Top-down with localized middle-out and then
implementation sequence middle-out support bottom-up acceptance
Adaptation Localized arrangements, then accommodating to an Legislated authority; brokered national agreement
agreed, state-wide model following extensive consultations
Agents Clinicians in intensive care units; later, managers and Policymakers and regulators; accreditation agencies;
policymakers; acceptance by admitting clinicians organizational adoption
in wards
Culture Positive values and attitudes amongst intensivists; Policy enactment from the highest levels as a driver of
eventual behavior and practice change across the eventual change through the hierarchy
system
Feedback Local clinicians influencing each other recursively for Policy implementation model: Ministerial endorsement,
many years; eventually, formal design and ongoing consultation and education leading to
implementation to reinforce and institutionalize the dampening of opposition and widespread take-up and
agreed framework adoption
Networks Intensive care physicians as prime movers; later, Policy and accreditation bodies, with research partners
policymakers, managers, and other clinicians lending expertise and support
Path dependence Thirty years in the making, leading to eventual Ten years of policy and managerial discussion and
acceptance against systems and clinical inertia maneuvering before implementation
Type of perturbation Gradual radiation of acceptance over time nationally Legislation as an enabler, acting as an initial mover
and internationally
Self-organization Intensive care physicians particularly; followed by Influence groups of policymakers, managers and
whole-of-system acceptance academics followed by big-bang introduction
Tipping point Growing acceptance by clinicians leading to leaders Ministerial authority, legislative enactment, sustained
eventually invoking the authority of the Clinical pressure from peak bodies, eventual system-wide
Excellence Commission acceptance
Braithwaite et al. BMC Medicine (2018) 16:63 Page 13 of 14

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