Understanding change in primary care practice using complexity theory

BACKGROUND. Understanding the organization of primary care practices is essential for implementing changes related to delivery of preventive or other health care services. A theoretical model derived from complexity theory provides a framework for understanding practice change. METHODS. Data were reviewed from brief participant observation fieldnotes collected in the 84 practices of the Direct Observation of Primary Care (DOPC) study and in 27 practices from three similar studies investigating preventive services delivery. These data were synthesized with information from an extensive search of the social science, nursing, and health services literature concerning practice organization, and of the literature on complexity theory from the fields of mathematics, physics, biology, management, medicine, and family systems, to create a complexity model of primary care practice. RESULTS. Primary care practices are understood as complex adaptive systems consisting of agents, such as patients, office staff, and physicians, who enact internal models of income generation, patient care, and organizational operations. These internal models interact dynamically to create each unique practice. The particular shape of each practice is determined by its primary goals. The model suggests three strategies for promoting change in practice and practitioner behavior: joining, transforming, and learning. CONCLUSIONS. This model has important implications for understanding change in primary care practice. Practices are much more complex than present strategies for change assume. The complexity model identifies why some strategies work in particular practices and others do not.