Managing system realignment through strategic coordination: A case study of multimorbidity in a Norwegian hospital

Healthcare systems are increasingly challenged by multimorbid patient trajectories that cut across specialized, siloed units, which introduces significant complexity that demands highly coordinated, adaptive efforts. By framing hospitals as open, multiunit systems, this study addresses how organizational units strategically realign themselves to manage system complexity in multimorbid healthcare delivery. A single-case study was conducted at a Norwegian university hospital. Using a qualitative multimethod approach, data were collected and analyzed by applying an extended case method scoped by patient trajectories (PTs) involving care and social services for children with concurrent somatic and mental health conditions. The study identified two overarching, complementary coordination strategies: (i) building internal coordination capability—through lateral relationships, the colocation of multidisciplinary staff, and digital interfaces—and (ii) limiting exposure to complexity—via trajectory modulation, dynamic resource allocation, and the selective buffering of cases. Rather than implementing these strategies in isolation, organizational units blended them into a dual strategic approach that was continuously adjusted to local resource constraints, professional discretion, and evolving patient needs. This duality yielded not only intended efficiencies, such as faster clinical decision-making and improved access, but also unintended vulnerabilities, including coordination overload or fragmentation, inequitable access, and the displacement of complexity to families or external providers. This study concludes that in complex healthcare systems, coordination is a strategic—not merely operational—imperative, for which managers must balance flexibility and control by actively designing interfaces that absorb variability without fragmenting care.