Table 4.

Case study comparisons – exemplifications of implementation science and complexity science paradigms

Selected implementation or complexity characteristic	Case 1: Rapid response systems’ adoption and spread	Case 2: Introduction of national quality standards
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