How Complexity Science Can Inform a Reflective Process for Improvement in Primary Care Processes

ORBIS International, New York, NY, USA.
Joint Commission journal on quality and patient safety / Joint Commission Resources 09/2005; 31(8):438-46.
Source: PubMed


Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices.
The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process.
Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change.
A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

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Available from: Reuben R Mcdaniel, May 20, 2014
    • "Hollnagel et al. (2011), Hollnagel and Woods (2005), Perrow (1984); reports on experiences of using complexity theory insights to support process improvement e e.g. Stroebel et al. (2005); Kernick (2004); and theoretical discussions on the use of complexity theory to enhance dimensions of organizational design e e.g. Snowden and Boone (2007). "
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    ABSTRACT: Although ergonomics has paid increasing attention to the perspective of complexity, methods for its operationalization are scarce. This study introduces a framework for the operationalization of the "attribute view" of complexity, which involves: (i) the delimitation of the socio-technical system (STS); (ii) the description of four complexity attributes, namely a large number of elements in dynamic interactions, a wide diversity of elements, unexpected variability, and resilience; (iii) the assessment of six management guidelines, namely design slack, give visibility to processes and outcomes, anticipate and monitor the impacts of small changes, monitor the gap between prescription and practice, encourage diversity of perspectives when making decisions, and create an environment that supports resilience; and (iv) the identification of leverage points for improving the STS design, based on both the analysis of relationships among the attributes and their classification as irreducible/manageable complexity, and liability/asset. The use of the framework is illustrated by the study of an emergency department of a University hospital. Data collection involved analysis of documents, observations of work at the front-line, interviews with employees, and the application of questionnaires. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.
    Applied ergonomics 09/2015; 50. DOI:10.1016/j.apergo.2015.02.003 · 2.02 Impact Factor
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    • "Achieving mandated PACT goals such as interdisciplinary continuity of care for patient panels, new scheduling methods, and improved care transitions requires substantial local redesign.8 Prior literature on non-VA PCMH shows that model implementation is transformative, requiring multi-dimensional changes9 that continuously adapt to local context.10 We thus expected that implementation of PACT would necessitate an ongoing local quality improvement (QI) process, in addition to top-down mandates and education.11 "
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    ABSTRACT: Healthcare systems and their primary care practices are redesigning to achieve goals identified in Patient-Centered Medical Home (PCMH) models such as Veterans Affairs (VA)'s Patient Aligned Care Teams (PACT). Implementation of these models, however, requires major transformation. Evidence-Based Quality Improvement (EBQI) is a multi-level approach for supporting organizational change and innovation spread. To describe EBQI as an approach for promoting VA's PACT and to assess initial implementation of planned EBQI elements. Descriptive. Regional and local interdisciplinary clinical leaders, patient representatives, Quality Council Coordinators, practicing primary care clinicians and staff, and researchers from six demonstration site practices in three local healthcare systems in one VA region. EBQI promotes bottom-up local innovation and spread within top-down organizational priorities. EBQI innovations are supported by a research-clinical partnership, use continuous quality improvement methods, and are developed in regional demonstration sites. We developed a logic model for EBQI for PACT (EBQI-PACT) with inputs, outputs, and expected outcomes. We describe implementation of logic model outputs over 18 months, using qualitative data from 84 key stakeholders (104 interviews from two waves) and review of study documents. Nearly all implementation elements of the EBQI-PACT logic model were fully or partially implemented. Elements not fully achieved included patient engagement in Quality Councils (4/6) and consistent local primary care practice interdisciplinary leadership (4/6). Fourteen of 15 regionally approved innovation projects have been completed, three have undergone initial spread, five are prepared to spread, and two have completed toolkits that have been pretested in two to three sites and are now ready for external spread. EBQI-PACT has been feasible to implement in three participating healthcare systems in one VA region. Further development of methods for engaging patients in care design and for promoting interdisciplinary leadership is needed.
    Journal of General Internal Medicine 04/2014; 29(S2). DOI:10.1007/s11606-013-2703-y · 3.42 Impact Factor
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    • "identified six guidelines for the management of CSS, based on a literature review of: studies that have used insights from complexity theory for designing CSS (e.g., Dekker, 2011; Hollnagel et al., 2011; Hollnagel and Woods, 2005; Perrow, 1984); reports on practical experiences of using complexity theory insights to support process improvement (e.g., Stroebel et al., 2005; Kernick, 2004); and theoretical discussions on the use of complexity theory to enhance dimensions of organizational design (e.g., Snowden and Boone, 2007). Table 1 summarizes the guidelines. "
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    ABSTRACT: While lean construction supports the management of complexity, a set of guidelines has not yet been articulated and explicitly linked to complex systems theory. In this study, six guidelines for managing complex socio-technical systems (CSS), proposed by the authors of this paper in an earlier work, are adopted as a basis. The guidelines are: (a) design slack; (b) encourage diversity of perspectives when making decisions; (c) anticipate and monitor the impact of small changes; (d) monitor the gap between guideline and practice; (e) give visibility to processes and outcomes; and (f) create an environment that supports resilience. The applicability of the guidelines to construction is illustrated by an exploratory study of a refurbishment project. Also, as the use of the guidelines only makes sense in a CSS, the investigated project is described according to a set of characteristics of complexity.
    21th Annual Conference of the International Group for Lean Construction, Fortaleza, Brazil; 07/2013
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