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Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya

机译：医院作为复杂的自适应系统：在肯尼亚医院水平中影响优先级规定实践的因素研究

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There is a dearth of literature on priority setting and resource allocation (PSRA) practices in hospitals, particularly in low and middle income countries (LMICs). Using a case study approach, we examined PSRA practices in 2 public hospitals in coastal Kenya. We collected data through a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations of PSRA practices in case study hospitals over a period of 7 months. In this paper, we apply complex adaptive system (CAS) theory to examine the factors that influence PSRA practices. We found that PSRA practices in the case hospitals were influenced by, 1) inadequate financing level and poorly designed financing arrangements, 2) limited hospital autonomy and decision space, and 3) inadequate management and leadership capacity in the hospital. The case study hospitals exhibited properties of complex adaptive systems (CASs) that exist in a dynamic state with multiple interacting agents. Weaknesses in system 'hardware' (resource scarcity) and 'software' (including PSRA guidelines that reduced hospitals decision space, and poor leadership skills) led to the emergence of undesired properties. The capacity of hospitals to set priorities should be improved across these interacting aspects of the hospital organizational system. Interventions should however recognize that hospitals are CAS. Rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence. (C) 2016 The Author(s). Published by Elsevier Ltd.
机译：在医院的优先设定和资源分配（PSRA）实践中存在缺乏文献，特别是在低收入和中等收入国家（LMIC）。使用案例研究方法，我们在沿海肯尼亚的2个公立医院审查了PSRA实践。我们通过在案例研究医院（n = 72）的国家级政策制定者，医院管理人员和前线从业者的深入访谈组合收集数据（N = 72），审查医院计划和预算等文件，会议纪要和会计记录等文件，在7个月内学习医院的PSA实践的非参与者观察。在本文中，我们应用复杂的自适应系统（CAS）理论来检查影响PSRA实践的因素。我们发现案件医院的PSA实践受到1）款项的影响，融资水平不足，融资安排不足，2）有限的医院自主和决策空间，3）医院的管理和领导能力不足。案例研究医院的展示了具有多个交互代理的动态状态存在的复杂自适应系统（CASS）的性质。系统“硬件”（资源稀缺）和“软件”（包括减少医院决策空间的PSA指南，领导技能差）的弱点导致了不期望的特性。在医院组织系统的这些互动方面，应提高医院设定优先事项的能力。然而，干预措施应认识到医院是CAS。他们应该努力为生产效率产生的条件来纠正系统的隔离方面。 （c）2016提交人。 elsevier有限公司出版

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