There is growing interest in the potential for complex systems perspectives in evaluation. This reflects a move away from interest in linear chains of cause-and-effect, towards considering health as an outcome of interlinked elements within a connected whole. Although systems-based approaches have a long history, their concrete implications for health decisions are still being assessed. Similarly, the implications of systems perspectives for the conduct of systematic reviews require further consideration. Such reviews underpin decisions about the implementation of effective interventions, and are a crucial part of the development of guidelines. Although they are tried and tested as a means of synthesising evidence on the effectiveness of interventions, their applicability to the synthesis of evidence about complex interventions and complex systems requires further investigation. This paper, one of a series of papers commissioned by the WHO, sets out the concrete methodological implications of a complexity perspective for the conduct of systematic reviews. It focuses on how review questions can be framed within a complexity perspective, and on the implications for the evidence that is reviewed. It proposes criteria which can be used to determine whether or not a complexity perspective will add value to a review or an evidence-based guideline, and describes how to operationalise key aspects of complexity as concrete research questions. Finally, it shows how these questions map onto specific types of evidence, with a focus on the role of qualitative and quantitative evidence, and other types of information.

Despite the global burden of perinatal deaths, there is currently no single, globally-acceptable classification system for perinatal deaths. Instead, multiple, disparate systems are in use world-wide. This inconsistency hinders accurate estimates of causes of death and impedes effective prevention strategies. The World Health Organisation (WHO) is developing a globally-acceptable classification approach for perinatal deaths. To inform this work, we sought to establish a consensus on the important characteristics of such a system.
A group of international experts in the classification of perinatal deaths were identified and invited to join an expert panel to develop a list of important characteristics of a quality global classification system for perinatal death. A Delphi consensus methodology was used to reach agreement. Three rounds of consultation were undertaken using a purpose built on-line survey. Round one sought suggested characteristics for subsequent scoring and selection in rounds two and three.
The panel of experts agreed on a total of 17 important characteristics for a globally-acceptable perinatal death classification system. Of these, 10 relate to the structural design of the system and 7 relate to the functional aspects and use of the system.
This study serves as formative work towards the development of a globally-acceptable approach for the classification of the causes of perinatal deaths. The list of functional and structural characteristics identified should be taken into consideration when designing and developing such a system.

The purpose of this paper is to describe how HealthPartners health system in Minneapolis, MN, has translated a clinical guideline for obesity among adults into an efficient care delivery practice operations system. Based on a foundation provided by the physician-led Institute of Clinical Systems Improvement (ICSI)-developed Prevention and Management of Obesity for Adults Health Care Guideline, HealthPartners adapted the guideline into an electronic health record-based \"Smart Set\" that provides frontline physicians with the information, treatment options, and referral steps necessary to care for their patients with obesity. Additional context is provided in terms of insurance coverage and systems-based resources designed to prevent and treat obesity for adults.

Deviations from accepted practice guidelines and protocols are poorly understood, yet some deviations are likely to be deliberate and carry potential for patient harm. Anaesthetic teams practice in a complex work environment and anaesthetists are unusual in that they both prescribe and administer the drugs they use, allowing scope for idiosyncratic practise. We aimed to better understand the intentions underlying deviation from accepted guidelines during drug administration in simulated cases. An observer recorded events that may have increased the risk of patient harm (\'Events of Interest\' [EOIs]) during 20 highly realistic simulated anaesthetic cases. In semi-structured interviews, details of EOIs were confirmed with participating anaesthetic teams, and intentions and reasoning underlying the confirmed deviations were discussed. Confirmed details of EOIs were tabulated and we undertook qualitative analysis of interview transcripts. Twenty-four EOIs (69% of 35 recorded) were judged by participants to carry potential for patient harm, and 12 (34%) were judged to be deviations from accepted guidelines (including one drug administration error). Underlying reasons for deviations included a strong sense of clinical autonomy, poor clinical relevance and a lack of evidence for guidelines, ingrained habits learnt in early training, and the influence of peers. Guidelines are important in clinical practice, yet self-identified deviation from accepted guidelines was common in our results, and all but one of these events was judged to carry potential for patient harm. A better understanding of the reasons underlying deviation from accepted guidelines is essential to the design of more effective guidelines and to achieving compliance.