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The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.

Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.

The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.

The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.

Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.

Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

The questions addressed by this review are: first, what are the guiding principles underlying efforts to stimulate sustained cultural change; second, what are the mechanisms by which these principles operate; and, finally, what are the contextual factors that influence the likelihood of these principles being effective? The paper aims to discuss these issues.

The authors conducted a literature review informed by rapid realist review methodology that examined how interventions interact with contexts and mechanisms to influence the sustainability of cultural change. Reference and expert panelists assisted in refining the research questions, systematically searching published and grey literature, and helping to identify interactions between interventions, mechanisms and contexts.

Six guiding principles were identified: align vision and action; make incremental changes within a comprehensive transformation strategy; foster distributed leadership; promote staff engagement; create collaborative relationships; and continuously assess and learn from change. These principles interact with contextual elements such as local power distributions, pre-existing values and beliefs and readiness to engage. Mechanisms influencing how these principles sustain cultural change include activation of a shared sense of urgency and fostering flexible levels of engagement.

The principles identified in this review, along with the contexts and mechanisms that influence their effectiveness, are useful domains for policy and practice leaders to explore when grappling with cultural change. These principles are sufficiently broad to allow local flexibilities in adoption and application.

This is the first study to adopt a realist approach for understanding how changes in organizational culture may be sustained. Through doing so, this review highlights the broad principles by which organizational action may be organized within enabling contextual settings.

The purpose of this paper is to present a case study of the World Health Organization’s Global Healthcare Workforce Alliance (GHWA). Based on a commissioned evaluation of GHWA, it applies network theory and key concepts from systems thinking to explore network emergence, effectiveness, and evolution to over a ten-year period. The research was designed to provide high-level strategic guidance for further evolution of global governance in human resources for health (HRH).

Methods included a review of published literature on HRH governance and current practice in the field and an in-depth case study whose main data sources were relevant GHWA background documents and key informant interviews with GHWA leaders, staff, and stakeholders. Sampling was purposive and at a senior level, focusing on board members, executive directors, funders, and academics. Data were analyzed thematically with reference to systems theory and Shiffman’s theory of network development.

Five key lessons emerged: effective management and leadership are critical; networks need to balance “tight” and “loose” approaches to their structure and processes; an active communication strategy is key to create and maintain support; the goals, priorities, and membership must be carefully focused; and the network needs to support shared measurement of progress on agreed-upon goals. Shiffman’s middle-range network theory is a useful tool when guided by the principles of complex systems that illuminate dynamic situations and shifting interests as global alliances evolve.

This study was implemented at the end of the ten-year funding cycle. A more continuous evaluation throughout the term would have provided richer understanding of issues. Experience and perspectives at the country level were not assessed.

Design and management of large, complex networks requires ongoing attention to key issues like leadership, and flexible structures and processes to accommodate the dynamic reality of these networks.

This case study builds on growing interest in the role of networks to foster large-scale change. The particular value rests on the longitudinal perspective on the evolution of a large, complex global network, and the use of theory to guide understanding.

This study investigates system dynamics (SD) applications in performance measurement (PM) research and practice. A bibliometric analysis was conducted to investigate the maturity of this research area and identify opportunities for development.

A systematic literature review (SLR) was conducted to provide a comprehensive and rigorous review of the existing literature. The search was conducted on 10 platforms identifying 97 publications, which were evaluated using bibliometric analysis.

The analysis revealed that applications of SD are most commonly used in the PM system design phase to model organisational performance. In addition, the bibliometric results showed a highly dispersed author set, with most studies using exploratory methods, suggesting that the research is in a relatively early stage of development. The results also showed that over 50 per cent of the causal models were not validated, emphasizing an important methodological gap in this research area.

This SLR is limited to indexed publications on 10 platforms, the search strategy was relatively precise and only available papers in English language were used for the literature review.

PM systems supported by SD can help managers understand and improve organisational behaviours by addressing dynamic complexities and relationship between variables. This study evaluates the maturity of this research area including information about the current development of this area and opportunities to build on existing knowledge.

This study identifies how SD approaches are applied to PM and highlights areas that require further research consideration. This paper is the first of two publications to result from this study and focuses on evaluating the current state of this research area.

A systematic literature review (SLR) was used to identify and analyze literature related to use of system dynamics (SD) applications in organizational performance measurement (PM) research. The purpose of this article is to present the results of a thematic analysis (TA) conducted to synthesize existing empirical evidence, investigate trends and evaluate developments in the research area.

A SLR was conducted resulting in a dataset of 97 articles in this research area. Using TA, major themes/subthemes were inductively synthesized to explore the current development and emerging trends and provide guidance for future research.

The TA resulted in seven themes in the research area – Enhancing knowledge, Approaches to operationalizing PM systems, Utilizing simulation models, Improving organizational outcomes, Achieving strategic alignment, Applying systems thinking and Identifying critical variables. The analysis suggests that although SD has the potential to improve PM systems, there are many limitations and challenges that must be addressed to improve implementation and practical applications. In addition, the results showed that much of the work is exploratory and many fail to fully validate their models suggesting that this research is still in an relatively early phase of development.

The results of this study are limited to the 97 articles identified using the SLR protocol. Although the search was designed to be comprehensive, there may be other relevant literature that was excluded. Further, the TA was limited to addressing the research questions.

A key insight for managers is that these tools would support decision-makers in understanding performance behaviors and identifying performance drivers for improvement. This suggests that stakeholders can adopt the approach to improve understanding and effectiveness of PM, and to enhance strategic decision-making.

This study provides a distinct and thorough analysis of this research area by conducting an inductive synthesis of developments and challenges and guidance for future research and practice. The resulting thematic model, identified code definitions and proposed framework of strategies to overcome challenges, provide a general overview and resource to support future studies in the research area and facilitate practical use of SD capabilities to support PM.