title: A systems science perspective on the capacity for change in public hospitals.
abstract: Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109 Australia.
authors.forename: J
authors.identifier: 0000-0003-0296-4957
authors.initials: J
authors.lastname: Braithwaite
authors.affiliation: Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Westbrook
authors.affiliation: Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
authors.forename: E
authors.initials: E
authors.lastname: Coiera
authors.affiliation: Centre for Population Health Research, School of Health Sciences, The University of South Australia, Adelaide, Australia.
authors.forename: W B
authors.initials: WB
authors.lastname: Runciman
authors.affiliation: St Vincent's Clinical School, University of New South Wales, Sydney, Australia.
authors.forename: R
authors.initials: R
authors.lastname: Day
authors.affiliation: The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, Australia.|Intensive Care Unit, Liverpool Hospital, Sydney, Australia.
authors.forename: K
authors.initials: K
authors.lastname: Hillman
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109 Australia.
authors.forename: J
authors.initials: J
authors.lastname: Herkes
mesh_terms: D003661:Decision Support Techniques; D006779:Hospitals, Public / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D009936:Organizational Innovation; D013597:Systems Analysis
keywords: Complexity science; Health systems; Organisational change; Public health; Systems science