Stroebel Christine K, McDaniel Reuben R, Crabtree Benjamin F, Miller William L, Nutting Paul A, Stange Kurt C
ORBIS International, New York, NY, USA.
Jt Comm J Qual Patient Saf. 2005 Aug;31(8):438-46. doi: 10.1016/s1553-7250(05)31057-9.
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.
在小型独立基层医疗环境中，质量改进流程有时成效有限。这些流程的理论框架隐含地将组织理解为具有潜在可控组件的可预测系统。然而，大多数组织并不能用这个框架准确描述。复杂性科学更适合用于理解小型基层医疗实践。
多方法评估流程（MAP）/反思性自适应流程（RAP）以复杂性科学为依据。该流程是在一系列旨在理解和改进基层医疗实践的研究中开发出来的。一个案例说明了MAP/RAP流程的应用及影响。
反思性变革流程的指导原则如下：理解实践的愿景和使命有助于指导变革，学习和反思有助于组织适应并规划变革，变革过程中出现紧张和不适是至关重要且正常的，多元视角能促进适应性并为积极变革带来新见解。
将组织视为复杂自适应系统的反思性变革流程可能有助于实践实现可持续改进。
