Overarching strategy and implementation sequence |
Bottom-up followed by top-down implementation, with middle-out support |
Top-down with localized middle-out and then bottom-up acceptance |
Adaptation |
Localized arrangements, then accommodating to an agreed, state-wide model |
Legislated authority; brokered national agreement following extensive consultations |
Agents |
Clinicians in intensive care units; later, managers and policymakers; acceptance by admitting clinicians in wards |
Policymakers and regulators; accreditation agencies; organizational adoption |
Culture |
Positive values and attitudes amongst intensivists; eventual behavior and practice change across the system |
Policy enactment from the highest levels as a driver of eventual change through the hierarchy |
Feedback |
Local clinicians influencing each other recursively for many years; eventually, formal design and implementation to reinforce and institutionalize the agreed framework |
Policy implementation model: Ministerial endorsement, ongoing consultation and education leading to dampening of opposition and widespread take-up and adoption |
Networks |
Intensive care physicians as prime movers; later, policymakers, managers, and other clinicians |
Policy and accreditation bodies, with research partners lending expertise and support |
Path dependence |
Thirty years in the making, leading to eventual acceptance against systems and clinical inertia |
Ten years of policy and managerial discussion and maneuvering before implementation |
Type of perturbation |
Gradual radiation of acceptance over time nationally and internationally |
Legislation as an enabler, acting as an initial mover |
Self-organization |
Intensive care physicians particularly; followed by whole-of-system acceptance |
Influence groups of policymakers, managers and academics followed by big-bang introduction |
Tipping point |
Growing acceptance by clinicians leading to leaders eventually invoking the authority of the Clinical Excellence Commission |
Ministerial authority, legislative enactment, sustained pressure from peak bodies, eventual system-wide acceptance |