Intended for healthcare professionals

Education And Debate Complexity science

Complexity, leadership, and management in healthcare organisations

BMJ 2001; 323 doi: (Published 29 September 2001) Cite this as: BMJ 2001;323:746
  1. Paul E Plsek, director (,
  2. Tim Wilson, director, St Paul RCGP Quality Unitb
  1. a Paul E Plsek & Associates, 1005 Allenbrook Lane, Roswell, GA 30075, USA
  2. b Royal College of General Practitioners, London SW7 1P
  1. P E Plsek

    This is the third in a series of four articles

    Current management thinking largely assumes that a well functioning organisation is akin to a well oiled machine.1 This leads to the notion that performance is optimised when work is specified in detail and shared out to distinct operational units.2 Clinicians often object to these detailed specifications, while managers bemoan a lack of cooperation.3

    The first article in this series introduced an alternative to the machine metaphor; that of a complex adaptive system (CAS).4 In this article we describe applications of complexity thinking in the organisation and management of health care.

    Summary points

    Management thinking has viewed the organisation as a machine and believed that considering parts in isolation, specifying changes in detail, battling resistance to change, and reducing variation will lead to better performance

    In contrast, complexity thinking suggests that relationships between parts are more important than the parts themselves, that minimum specifications yield more creativity than detailed plans

    Treating organisations as complex adaptive systems allows a new and more productive management style to emerge in health care

    Embedded Image

    (Credit: LIANE PAYNE)

    Whole system performance: managing generative relationships

    The interactions within a complex adaptive system are often more important than the discrete actions of the individual parts. As the examples below illustrate, a productive or generative relationship occurs when interactions among parts of a complex system produce valuable, new, and unpredictable capabilities that are not inherent in any of the parts acting alone.5

    Although health care depends largely on productive interaction, the organisation and management of its delivery surprisingly does not always reflect this insight. In the United Kingdom, for example, having separate budgets and performance targets for primary care, secondary care, and social services promotes an internal focus on the operation of each of these parts, but not necessarily the good functioning of …

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