Department of Family Medicine, Robert Wood Johnson Medical School, Somerset, NJ 08873, USA.
Med Care. 2011 Dec;49 Suppl(Suppl):S28-35. doi: 10.1097/MLR.0b013e3181cad65c.
Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches.
Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change.
A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice.
It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.
尽管美国广泛采用了基于知识转移方法来提高临床绩效的改进策略，但临床护理仍存在严重缺陷。最近呼吁将初级保健实践转变为以患者为中心的医疗之家，这带来了更大的挑战，需要更有效的方法。
我们的研究团队开展了一系列由美国国立卫生研究院资助的描述性和干预性项目，以从复杂科学的角度理解初级保健实践环境中的组织变革。这一系列研究促成了一项发展性研究，确定了与促进实践变革相关的关键经验教训。
对 15 年研究计划的结果进行了总结，强调了从当前或传统的质量改进方法所基于的机械论角度来看待初级保健实践的局限性。将初级保健实践视为具有“主体”的动态复杂适应系统的理论视角，这些主体具有学习能力，并且可以以不可预测的方式自由行动，为基础质量改进策略提供了更好的框架。该框架强烈强调，质量改进干预措施不仅应采用复杂系统的视角，还需要不断反思、精心调整干预措施，并持续关注实践中主体之间的相互作用的质量。
如果没有更强大的指导理论基础，当前的质量改进策略不太可能成功地将当前的初级保健实践转变为以患者为中心的医疗之家。我们的工作表明，以复杂性科学为指导的理论框架可以帮助制定质量改进策略，更有效地促进实践变革。
