Quality improvement in Australian general practice: a complexity perspective

Abstract

Persistent demand for continuous improvement in the quality of health care is fuelled by data on sub-optimal care, changing patterns of illness, rising expectations and escalating costs. The quality improvement research focus has expanded beyond individual professional development to include organisational behaviour, yet reliable prescriptions to implement change in practice remain elusive. This research examined this dilemma in Australian general practice and explored how a complexity perspective on organisational change might enhance understanding of quality improvement. An embedded qualitative case study at local practice and national policy levels was used to test the fit and explanatory worth of both complexity and traditional approaches against the empirical reality of change for better chronic illness care over eleven years. Data were sourced from document review, direct observation and interviews, both in a single practice selected for its reputation for quality and its potential for learning, and among six key policy informants involved in chronic care reform over the period of interest. Results revealed considerable re-shaping of general practice at local and national levels in line with research findings and policy initiatives for enhanced chronic illness care. Change was, however, uneven and unpredictable and fitted the pattern envisaged by complexity thinking better than traditional linear models of planned improvement. Key complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics were evident in a network of agents and relationships comprising self-aware persons involved in communicative gestures and responses influenced by power and values-based choices. The changing order of general practice emerged from this local interaction. Complexity theory, interpreted this way through a sociological and psychological lens, offered a more satisfying explanation for the frustrating lack of reliable improvement formulae. These findings raise awareness of limitations in the current discourse in health care improvement and support a complex responsive processes approach to enhance traditional understanding of organisational change. They offer guidance and encouragement for participant leaders in the challenging business of improving health care. They are themselves a communicative gesture which may elicit new responses and influence the discourse within the ongoing conversation of quality improvement.