Mildred Visser

Background and conceptual framing of the dissertation
Healthcare organisations face the challenge of improving patient outcomes while managing rising costs, workforce pressures and growing organisational complexity. In this context, care pathway development and value-based healthcare have increasingly converged as complementary strategies for organising, improving and evaluating care. Within value-based healthcare, care pathway development has emerged as a central strategy to organise care around patients’ needs, outcomes and resource use. However, widely used care pathway development methods often assume relatively stable contexts and relatively linear implementation processes, offering limited guidance on how multidisciplinary teams navigate value tensions, boundary dynamics and contextual change in everyday development practice. This dissertation argues that complexity is not an external challenge to care pathway development but constitutive of how development itself unfolds.

This dissertation addresses this gap by examining how care pathway development unfolds in dynamic organisational contexts characterised by interacting forms of complexity. Rather than studying individual pathways, the dissertation adopts a programme-level perspective in which multiple care pathways are developed in parallel within a shared programme structure. This perspective enables empirical insight into how value-based quality improvement unfolds through multidisciplinary collaboration over time.

The dissertation draws on a longitudinal action research programme conducted in a Dutch specialised rehabilitation hospital, in which multidisciplinary teams developed multiple care pathways in parallel. The programme combined care pathway development with recurring cycles of planning, action and reflection, enabling close examination of how pathway development unfolded over time.

The overarching aim of this dissertation is to examine how care pathway development unfolds in dynamic organisational contexts characterised by multiple, interacting forms of complexity and how such complexity can be navigated in practice. To this end, this dissertation retrospectively identifies four interconnected, heuristic layers of complexity, each illuminating a distinct dimension through which complexity in care pathway development becomes visible in practice:

• a structural layer (programme complexity), focusing on the complexity that arises in organising and coordinating programmes for care pathway development at the programme level;
• an interactional layer (boundary complexity), focusing on the complexity that arises when multidisciplinary teams collaborate across professional and organisational boundaries;
• an interpretive layer (discursive complexity), focusing on how professionals’ and managers’ beliefs and discourses about patient and public involvement shape whether, when and how such involvement takes place in care pathway development;
• a normative layer (value complexity), focusing on how tensions between multiple and sometimes competing values, such as care quality, efficiency, financial viability and professional autonomy, shape goal alignment and decision-making.

Empirical findings across four layers of complexity
This dissertation examines care pathway development through four interconnected layers of complexity: structural, interactional, interpretive and normative. Each empirical chapter addresses one layer, together providing an integrated account of how care pathway development unfolds in dynamic organisational contexts.

The structural complexity layer is examined in Chapter 2, which studies how multiple care pathways were developed in parallel within a coordinated programme. The findings show that parallel pathway development generated recurring programme-level challenges. Principle-based programme structures provided direction and coherence while requiring ongoing adjustment in response to contextual change. Action research enabled phased implementation and continuous adaptation of the programme, supporting reflective learning while navigating tensions between programme structures and evolving organisational conditions.

The interactional layer is explored in Chapter 3, which examines how boundary work shaped multidisciplinary teams’ value-based quality improvement efforts. Three forms of boundary work were identified: competitive, collaborative and configurative. Collaborative boundary work supported trust, shared decision-making and improvement progress, whereas competitive boundary work constrained engagement and slowed progress. Configurative boundary work, typically enacted by advisors, created enabling conditions for collaboration but also introduced dependency risks.

The interpretive layer is addressed in Chapter 4, which examines professionals’ and managers’ beliefs about patient and public involvement in care pathway development. The study identified distinct discursive repertoires that framed patient involvement as essential , conditionally valuable or problematic. These discourses shaped when, how and to what extent patients were involved. Beliefs about feasibility, representativeness, vulnerability and professional responsibility influenced the postponement, restriction or avoidance of involvement.

The normative layer is examined in Chapter 5, which explores how the coexistence of multiple and sometimes competing values shaped care pathway development. Tensions between care quality, efficiency, financial viability and professional autonomy influenced goal alignment and decision-making. These tensions were navigated through pragmatic adjustment, including reflective dialogue, small-scale experimentation and financial modelling that helped teams sustain progress despite recurring value tensions. Rather than resolving these tensions, teams arrived at provisional stabilisations, temporary, workable alignments that allowed development to continue without requiring consensus or final resolution. These periods of negotiation and recalibration (what this dissertation refers to as the ‘messy middle’ of care pathway development) characterised the empirical process across all four studies.

A complexity-informed approach to care pathway development
Chapter 6 synthesises the empirical findings to develop a complexity-informed approach to care pathway development and addresses the overarching research question: how can the complexity of care pathway development in dynamic organisational contexts be understood and navigated? The synthesis positions complexity not as an obstacle to be reduced or controlled but as constitutive of care pathway development itself. Structural, interactional, interpretive and normative complexities emerge simultaneously and interact as development unfolds across programme and team levels.

Within this perspective, navigating these complexities requires recurring reflective and adaptive cycles that enable actors to engage with emerging forms of complexity over time as development unfolds. Reflective cycles support collective sensemaking by examining how assumptions, interpretations and value judgements shape development processes across the four layers of complexity. Through reflective dialogue, actors surface implicit assumptions, boundary dynamics and value tensions that influence development trajectories. Adaptive cycles translate these insights into adjustments to programme structures, facilitation strategies and development directions, such as revising programme pacing, redefining ambitions or restructuring collaboration arrangements.

Together, reflective and adaptive cycles constitute the central mechanism through which actors navigate complexity in care pathway development. As a result, development unfolds through ongoing cycles of sensemaking and adjustment rather than through predefined implementation steps. Organising such cycles requires structures that connect reflection and action over time. In this programme, action research provided such an enabling infrastructure by linking planning, action and reflection, while legitimising ongoing programme adjustment and collective learning. Where the conditions for action research are not available, action learning offers a legitimate and distinct alternative that preserves the reflective-adaptive orientation without claiming scientific rigour it cannot deliver.

Figure 6.1 visualises the interplay between reflective and adaptive cycles as the core mechanism of the approach. Figure 6.2 synthesises the complexity-informed approach as a whole, showing how a broadly phased, method-independent development process is continuously shaped by the four layers of complexity and by the ongoing interplay between reflective and adaptive cycles.

Contribution of the dissertation
This dissertation makes three interrelated contributions.

Theoretically, it advances understanding of care pathway development as a reflective and adaptive practice by arguing that complexity is constitutive of how development unfolds, shaped by interacting layers of complexity. It provides an empirically grounded conceptualisation of how actors involved in care pathway development navigate complexity across programme and team levels during value-based quality improvement. In addition, the dissertation develops a complexity-informed approach in which reflective and adaptive cycles constitute the central mechanism for engaging with complexity in practice.

Practically, the dissertation shows how care pathway development programmes can be organised to support reflective and adaptive cycles. The findings highlight the importance of creating protected spaces for dialogue, legitimising pauses for reflection alongside action, and supporting facilitation roles that help surface boundary dynamics and value tensions.

Methodologically, the dissertation demonstrates how action research can support and study care pathway development under conditions of complexity. It highlights the importance of reflexivity, role awareness and balancing practical engagement with scientific distance in embedded research settings. It further shows that where sustained academic–practice collaboration is not available, action learning offers a practice-oriented alternative that preserves the core reflective-adaptive principles.

Conclusion
This dissertation develops a complexity-informed approach to care pathway development that foregrounds reflective and adaptive cycles as the central mechanism through which complexity is engaged in practice. Care pathway development unfolds through the ongoing interaction of structural, interactional, interpretive and normative complexities within dynamic organisational contexts. Sustained progress therefore depends less on adherence to predefined development steps and more on the capacity of teams and programmes to organise and sustain recurring cycles of collective reflection and adaptive adjustment. By integrating empirical findings with theoretical and methodological reflection, the dissertation contributes to more reflexive, adaptive and complexity-informed approaches to care pathway development and value-based quality improvement in healthcare.