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