UNDERSTANDING CHANGE IN PRIMARY-CARE PRACTICE USING COMPLEXITY THEORY

BACKGROUND. Understanding the organization of primary care practices i s essential for implementing changes related to delivery of preventive or other health care services. A theoretical model derived from compl exity theory provides a framework for understanding practice change. M ETHODS. Data were reviewed from brief participant observation fieldnot es collected in the 84 practices of the Direct Observation of Primary Care (DOPC) study and in 27 practices from three similar studies inves tigating preventive services delivery. These data were synthesized wit h 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 pr actices are understood as complex adaptive systems consisting of agent s, such as patients, office staff, and physicians, who enact internal models of income generation, patient care, and organizational operatio ns. These internal models interact dynamically to create each unique p ractice. The particular shape of each practice is determined by its pr imary goals. The model suggests three strategies for promoting change in practice and practitioner behavior: joining, transforming, and lear ning. CONCLUSIONS. This model has important implications for understan ding change in primary care practice. Practices are much more complex than present strategies for change assume. The complexity model identi fies why some strategies work in particular practices and others do no t.