Complexity

Perceived intricacy or difficulty of the intervention, reflected by intervention type (e.g., behavior change or plug-in technology), duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement [1][2]. Radical interventions require significant reorientation and non-routine processes to produce fundamental changes in the organization’s activities and reflects a clear departure from existing practices [1]. One way to determine complexity is by assessing ‘length’ (the number of sequential sub-processes or steps for using or implementing an intervention) and ‘breadth’ (number of choices presented at decision points) [3]. Complexity is also increased with higher numbers of potential target organizational units (teams, clinics, departments) or types of people (providers, patients, managers) targeted by the intervention [3], and the degree to which the intervention will alter central work processes [2].

Appropriately diagnosing and assessing complexity is thought to benefit implementation by avoiding unintended consequences [3]. There is a negative association between stakeholder’s perception of how complex an intervention is and effective implementation (i.e., simple interventions are more likely to be effective) [1][4] because it affects user satisfaction and the speed required to be competent in using the interventions [5]. The ability to implement an intervention incrementally (sometimes referred to as divisibility [2]; see Executing) can influence perception of complexity.

The type of intervention, whether a technical (e.g., a new computer module) or an administrative change (behavioral change), can contribute to the perception of complexity. Technical interventions may include a purchased product, packaged service, or an automated production process (e.g., computerized order entry). Administrative interventions primarily affect organizational social structures or processes. Most interventions are a hybrid of both. Technical interventions tend to be more visible and administrative interventions tend to be more complex and difficult to implement [1]. On the other hand, complex behavioral change interventions can also work in favor of implementation. If organizations embrace an intervention as a fundamental change to processes up front, they are more likely to do what it takes to fully and effectively implement the intervention compared to sites that regard it as a simple “plug-in” intervention [6]. Edmondson and colleagues describe a “technological frame” of thinking that influences implementation effectiveness. In their study of a new cardiac surgical approach, the sites with less successful implementation viewed the intervention as a “plug-in technology” while those with better implementation effectiveness regarded the intervention “as fundamental change for the [operating] team” [6] and had more engaged support by key stakeholders (see Leadership Engagement and Engaging: Key Stakeholders). Regardless of the degree of complexity, simple, clear, and detailed implementation plans, schedules, and task assignments contribute to successful implementation [4].