mutual adjustment, Plsek said. Professional organizations also coordinate under the standardization of norms mechanism, so that an understanding of the norm exists (e.g., having a zero infection rate). To achieve the end goals, the people leading change—the change agents—have the choice of either attempting to force organizations to work against their natural coordination mechanisms or reframing the needed change in a way that takes advantage of these natural mechanisms.

Second, behavior in complex adaptive systems can largely be explained by attractors. Again, change agents have two choices: attempting to directly confront and change others’ behaviors and motivators, or reframing the needed change in ways that leverage people’s innate reasons for doing what they do.

The third characteristic of complex systems is that integrated changes in structures, processes, and patterns are required for sustainable transformation. Structures refer to the physical environment and policies; processes may be guidelines and protocols; and patterns reflect behaviors and the nature of relationships, decision making, conflict, power, and learning. Understanding of all three is necessary for transformation to occur. For example, adoption of electronic medical records would be a structural change, which must be accompanied by processes such as guidelines. However, improvements may not be sustainable if people do not feel included in decision making, or if conflict avoidance behavior occurs when certain powerful individuals refuse to use the system as it was designed.

Answering the questions mentioned in the beginning of his talk, Plsek said the spread of improvement is complex. Improvement in health care spreads much slower in comparison to other industries. Perhaps this is because the coordination strategies that work in other industries do not necessarily apply in health care. Finally, with respect to what can be done to enhance the likelihood of spread, Plsek said that spread cannot be forced and that context plays a large role. People conducting interventions need to be more conscious of the interventions so that factors contributing to spread can be identified. Storytelling is as important as evidence-based research findings to improve spread of ideas. People have to be willing to change, and change has to start somewhere in the current culture of the organization (the mechanism of mutual adjustment). People also have to be willing to adapt, while the leadership of an organization must be willing to “muddle through,” which, Plsek said, has been an effective strategy in complex systems.

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