Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia.
BMC Fam Pract. 2013 Apr 23;14:51. doi: 10.1186/1471-2296-14-51.
Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens.
This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology.
The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives--re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices.
The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare.
将循证实践纳入常规医疗保健的兴趣从未如此之大。在老龄化人口中，基层医疗面临着管理日益增加的慢性疾病负担的挑战。尽管进行了大量的研究和出版活动，但将知识转化为实践的可靠方法仍然难以捉摸。本研究通过挑战当前关于医疗保健改善的思维方式，探索了一般实践中的这一困境，并通过复杂性视角审视变化，探讨了从中可以学到什么。
本文报告了一项嵌入式案例研究的地方层面，该研究涉及十多年来改善慢性疾病护理的组织变革。我们使用访谈、文件审查和直接观察来探讨一个实践中如何改善慢性疾病护理。这形成了一个关键案例，通过模式匹配逻辑与常见的最佳证据局部实施处方和从复杂性科学中得出的竞争解释进行比较，该解释通过现代社会学和心理学进行了解释。
该实践在十多年的时间里不断变化，根据研究结果和政策倡议提供更好的慢性疾病护理，重新设计护理流程，发展社区联系，支持患者自我管理，使用指南和临床信息系统，并将护士纳入实践团队。这些改进都不是根据明确的计划设计和实施的，以响应慢性疾病护理中记录的差距。导致高质量慢性疾病护理的过程表现出明显的复杂性特征，如共同进化、非线性、自组织、涌现和混沌边缘动力学，这些特征存在于一个由代理和关系组成的网络中，其中一种稳定但不断发展的组织方式源于本地层面的沟通互动、权力关系和基于价值观的选择。
在这个一般实践改进的关键案例中，实施科学作为有计划的系统变革的当前话语与组织现实不匹配。以人类术语翻译的复杂性概念作为复杂的响应关系过程更准确地符合变化模式。它们不仅提供了另一种时尚的变革蓝图，而且还告知研究人员、政策制定者和提供者如何参与改善医疗保健。
