PhD defence M. (Mildred) Visser

Below is a brief summary of the dissertation:

How do you improve care when circumstances keep changing?

Healthcare is under pressure from rising demand, staff shortages and financial constraints. Care pathways are a widely used response: agreements on how care for a specific patient group is organised. Existing methods recognise care pathways as complex interventions shaped by context, but mainly offer successive phases. In practice, multidisciplinary teams work across departmental boundaries, with different interests and values, in a changing organisation. Fixed phases offer little guidance here.

In a Dutch rehabilitation hospital, Mildred Visser set up a programme where several teams developed care pathways simultaneously. She led it for several years while studying it as an action researcher. The study shows that complexity is not an external obstacle but shapes the development process. The programme structure provided direction but required regular adjustment. Three forms of boundary work were active simultaneously. Working together across boundaries supported trust and progress, protecting one’s own domain hindered it, and advisers created conditions for collaboration, at the risk of dependency. Patients were involved in only three of eleven teams, partly due to doubts among professionals and managers about feasibility, representativeness and vulnerability. Tensions between values such as quality, efficiency, financial feasibility and professional autonomy persisted, but through dialogue and small-scale experiments teams reached temporary, workable alignments.

From this, Visser developed a complexity-informed approach that fosters progress by systematically building recurring cycles of collective reflection and adjustment into pathway development. Organisations can support this with open dialogue, regular reflection and facilitation that surfaces tensions.