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Table 2 Categorization of changes implemented in individual clinical pathways and at the organizational level with illustrative examples

From: Make it complicated: a qualitative study utilizing a complexity framework to explain improvement in health care

Situation
(n = 53)
Problem definitionaResponseaPrimary locus of responsibility for the workKind of workDecision-making processa
Simple
18 (34%)
Clear
38 (72%)
Unnecessary visits by pregnant patients with suspected intrahepatic cholestasis because patients were seen more acutely than evidence suggests is warranted.
Clear
6 (11%)
To use recently developed regional guidelines to reduce unnecessary admissions due to trauma in pregnancy.
Manager
3 (6%)
Managers were responsible for introducing the new guideline on “trauma in pregnancy” in the electronic guideline collection.
Technical
3 (6%)
To implement the new guideline on “Trauma in pregnancy”.
Sense
Categorize
Respond
2 (4%)
Complicated
20 (38%)
Requires learning
47 (89%)
Developing networked, cross-sectional collaborations with interprofessional teams able to design individualized treatment plans for newborns who had lost weight.
Manager and staff
13 (24%)
Redesigning the physical space of the new obstetrics clinic by merging four units. Managers held the responsibility for changing the physical space and organizational structures and staff was responsible for developing and testing the new workflows and new patient pathways.
Technical and adaptive
32 (60%)
Reduce admissions due to postpartum hemorrhage. The technical work involved raising the limit for how much bleeding could be accepted without having to admit the patient for further observation. This change was based on the realization that the previous limits were based on insufficient evidence. The adaptive work involve changing the “better safe than sorry” culture.
Sense
Analyze
Respond
4 (8%)
Complex
15 (28%)
Requires learning
15 (28%)
How to redesign the physical space of the new obstetrics clinic that arose from the merger of four units to improve patient flow and coordination and collaboration across organizational and professional silos.
Staff > manager
37 (70%)
Responsibility for development of the group B streptococcal (GBS) test to prevent unnecessary administration of IV-antibiotics and the subsequent unnecessary admission for observation was held by a senior physician.
Adaptive
18 (34%)
Iterative approach to redesign the physical space and the flow of patients and staff in the obstetrical unit.
Probe
Sense
Respond
0 (0%)
  1. aThe problem definition and responses could not be differentiated for simple and complicated, and complicated and complex situations, respectively. The majority of the decision-making processes did not fit the theoretically pre-defined patterns as they involved more steps and are therefore not categorized in the table