Practice Jazz: Understanding Variation in Family Practices Using Complexity Science

One major focus of health services research and quality improvement efforts is to identify and reduce variation.^1-4 Standardization is the approach usually offered to minimize variation, thus reducing errors and increasing quality.^5,6 These interventions are often based on an industrial quality improvement paradigm⁷ using linear interventions that assume that inputs reliably lead to proportionate responses.⁸ These interventions include re-engineering and expanded information systems.^9,10 If the application of linear Newtonian views is correct, then standardization is the key to quality improvement, and effective practices will look much alike. The search for and attempt to implement best practice guidelines^11-14 are examples of efforts to bring practices into conformity and to establish process standards for best behavior. However, the search for simple, easily transportable interventions has not been as successful as traditional logic might suggest.^15-19

Emerging views of organizations derived from complexity science bring the key understanding that practices are more than commodity-delivering businesses—they are complex adaptive systems.²⁰ These systems involve connected participants interacting in ways that generate the spontaneous emergence of new structures and behaviors. In complex adaptive systems, we expect to see variation in practice patterns, even when the outcomes of practices are similar.

In a previous issue of JFP,²¹ we proposed a model of primary care practices as complex adaptive systems and suggested implications and strategies for change. Since then we have begun applying this theoretical framework to other studies designed to understand and advance generalist practice. Our present purpose is to advance the application of complexity science to understanding and improving primary care practices and their co-evolving health care systems.

The theory application process

The 3 studies that this theory application builds on began with the Direct Observation of Primary Care (DOPC) study, a 3-year (1994-1997) multimethod descriptive investigation of the content of 4454 patient visits to 138 family physicians in 84 family practices.^22,23 One of the outcomes of this study was a model for understanding change in family practice based on complexity science.²¹ Subsequently, The Prevention and Competing Demands in Primary Care Study (PCDPC) was a 3-year (1996-1999) in-depth descriptive case study of 1637 outpatient visits to 56 clinicians in18 family practices purposefully sampled to include diversity in geographic location, size of practice, and intensity of delivery of preventive services.²⁴ We also implemented a 4-year (1997-2001) multimethod clinical trial, the Study to Enhance Prevention by Understanding and Practice (STEP-UP), to understand and improve the delivery of preventive health services in 77 family practices.²⁵

We conducted an explicit theory application and refinement process consisting of 10 meetings to analyze data from DOPC, PCDPC, and STEP-UP, informed by a literature review of complexity science. The developing model was explicitly tested in 3 Nebraska family practices in 1999 in an effort to improve diabetes care.²⁶ The resulting specific theory application to family practices was then evaluated using 2 cases from these studies.

Application of complexity science to family practice

Synthesizing our observations of the family practices and the literature review, we developed the following theoretical model. Family practices are local professional complex adaptive systems with the primary purpose of seeing patients for everyday health concerns to assist “them” in getting on with their daily lives. “Them” refers to the patients and their families, the clinicians, and the office staff. Practice leaders and managers usually describe their practices in terms of efficiency, productivity, adherence to standards of care, and patient satisfaction. Increasingly, practices function in interactive ways with managers or owners from local health care systems. Still, these practices behaved more like complex adaptive systems operating within a professional milieu than like businesses.²⁷

Complex adaptive systems are like a family reunion; they are dynamic-bounded webs of diverse agents interacting nonlinearly.²⁸ Dynamic refers to the continual presence of multiple interactions and their accompanying surprises, challenges, and responses, both within the system and between the system (eg, practices) and its environment. Bounded refers to the defining purpose or intent of the system (eg, to deliver health care to local patients). The metaphor of a web characterizes the multiple interconnections of the system. The agents in practices include clinicians, office staff, and patients, and can also include pharmaceutical representatives, health care system administrators, and others. Agents have the capacity to exchange information, learn, and adjust their behavior. No individual agent can ever know or understand everything that is occurring. The nonlinear relationships among the agents are the result of ongoing feedback loops and mean that small changes can lead to large effects and big changes can lead to small effects. For example, the introduction of a small medical record stamp to identify smokers in one practice leads to a dramatic increase in smoking counseling, while a major quality improvement program in another practice results in minimal change.

What makes an organization “professional” is the application of specialized values and expertise to address difficult problems and uncertainty. These values and skills are acquired through specialized training and are created by the larger social context.²⁹ It is the socially defined professional values and expertise of the family physician that are applied in their daily activities. A co-evolving professional world of the health system and payer manager is increasingly interacting with the physician professional value system.

Each family practice is unique because of 5 features:

1. History and initial conditions,including any explicit or implicit mission and the underlying priorities for the practice.
2. Particular agents and their unique styles and interests.
3. The pattern of nonlinear interactions among agents.
4. The local fitness landscape(ie, the practice’s ecological niche) and its particular expectations, community values, competitive issues, and ecology.
5. Regional and global influences, such as larger health care systems, finances and regulations, and culture.

The local fitness landscape, a complexity science term from evolutionary biology, specifically refers to the local terrain and all the many complex adaptive systems, from microbes to organizations, that seek their own purpose and niche within that terrain. Biological evolution and technological evolution are processes attempting to optimize systems riddled with conflicting constraints.³⁰ Each family practice must evolve by attempting to optimize the entire package of services it delivers. This evolution must account for all the other competing and cooperating health care services and local resources, such as economic conditions, availability of insurance types, and the particular local disease and illness epidemiology.

How all of these factors manifest in a particular family practice at any given time and over time can be understood using 3 complexity science properties: self-organization, emergence, and co-evolution. Self-organization refers to the spontaneous development of structures and forms of behavior in systems characterized by multiple feedback loops and nonlinear dynamics. These structures are a function of the patterns of relationships among agents. Everything changes in response to and as a result of everything else, with each complex adaptive system seeking a better position in its local fitness landscape—a niche where it can prosper and survive.³¹ In this setting of ongoing co-evolution, both competition and collaboration become strategies for workable solutions. As the agents of any complex adaptive system interact, novelty and surprise continuously emerge in unpredictable ways. For example, a new successful approach to scheduling is introduced by an unassuming receptionist. This emergence creates a system that is greater than the sum of its parts; it is what cannot be understood through a reductionist (one problem at a time) examination of the practice.³²

A particular family practice is the unique self-organized system that emerges when particular physicians and staff (agents) come together in particular ways with particular goals, preferences, and priorities (initial conditions) within a particular community setting (local fitness landscape) given specific regional and global influences. At any future point, this practice is the unique self-organized system that has emerged through co-evolution with all the other systems in the local fitness landscape.

The result is much variation between and within family practices. Practices have much in common, however, because of their common goal of seeing patients to assist them with their everyday health problems in a shared cultural and historical context. From that perspective, variation in family practices is inevitable and a powerful source of creative possibility, value, and good clinical practice. Practices use 2 strategies for successfully enhancing that creativity: sensemaking and improvisation. Sensemaking is a social activity that requires interaction among agents.^33,34 People must come to have some notion of “Who am I,” “Why am I here,” and “What is going on around me?” Improvisation is a strategy for dealing with surprise in complex adaptive systems. Improvisation can be described as intuition guiding action in a spontaneous way.³⁵ Intuition is not a random guess at what to do, but the result of using high levels of expertise to act in the moment.^27,36

Among the many practices in the studies we are currently analyzing, multiple areas of variation are observed. These include differences in charting systems, clinical care decisions, scheduling, billing and coding procedures, staff relationships, and management and clinical styles. Sometimes these variations provide an adaptive advantage, but often not, and it is seldom clear in advance which will be true. Inflexible standardization, however, is often poorly responsive to the needs of different practices’ diverse agents and to the almost constant situations of uncertainty, contextual uniqueness, and surprise that occur in the practices.

Case studies

To illustrate the application of complexity science–based sensemaking to family practice, we present 2 case studies.

We selected 2 practices that had high quality of care as measured by delivery of preventive health services and patient satisfaction. One case takes advantage of the longitudinal data from DOPC and STEP-UP, and the other makes use of the more in-depth cross-sectional data from PCDPC. The cases were also selected to assure maximum variation in location and affiliation, and homogeneity in practice size (4-8 clinicians). The names have been changed to protect confidentiality.

Franchise Family Practice

History/Initial Conditions
Franchise is one of several primary care offices created by the Health Salute Corporation in affluent suburban areas of intense competition for market share growth. The corporate intent for this practice is to be productive and profitable. Two family physicians, a pediatrician, and a nurse practitioner were brought in from other practices, and several of their staff members followed. They all agree that their mission is to be the best practice in the Health Salute Corporation. Their identity is to capture market share through better efficiency, a mechanistic approach (scientific and standardized), and a friendly and caring attitude.

Agents and Patterns of Interaction
The practice manager’s daily attire in stockings and heels sets the tone for interactions, which are formal and professional. A small core of staff is dedicated to this practice, but there is often temporary help from other Health Salute offices during busy times. The patient population of predominantly mobile, insured, 2 working parent families tends to value convenience over relationships. The physicians seem to have little emotional investment in this particular practice, place, or each other. Conflicts are minimized and usually covered over with humor.

Local Fitness Landscape
There is no clear sense of community in this new suburb. Franchise is located in the heart of “minivan land,” an unrolling suburban carpet. The 2 competing systems are a major threat and are constantly being discussed. It is very clear that the survival of Franchise is dependent on success in the marketplace as determined by Health Salute.

Regional/Global Influences
Managed care has a strong presence, with much pressure to implement multiple practice guidelines, frequent chart audits, and different formularies.

Self-Organization
In many respects, Franchise Family Practice comes close to fulfilling its mission. Franchise is friendly, fun loving, and clean. It is a high performer at delivering preventive health services and is full of glitz and protocols. There are multiple systems in place for all phases of practice operation, and the manager sees they are working.

Emergence
Despite this managed order, surprises, problems, uncertainty, and complexities keep arising on a daily basis. Occasionally individuals respond creatively, but more often they stick to the protocols and generate even more trouble. There are frequent staff meetings where common problems are discussed. Many different solutions emerge in these discussions, but the final resolution is usually based on what the practice management thinks Health Salute would want. Even in this intensely structured practice, multiple competing demands, power distributions, and interpersonal battles are being simultaneously worked out on a daily basis.

Co-Evolution
As the suburbs grew, more practices were opened. The original practice in the area was soon challenged by Franchise and then by another competitor. Each of the 3 practices often acted or reacted in response to the others. Approximately a year after our research ended, Franchise Family Practice was closed by Health Salute because of inadequate profitability, and within a few months the second competitor also closed its practice.

Dusty Garden Family Practice

History/Initial Conditions
Dusty Garden began as a pioneering model for community-oriented primary care in an economically impoverished urban area. The practice was created with a focus on the patient in this underserved community. Envisioned by its founding family physician and practice manager, this practice was established in close collaboration with a community board. Survival is dependent on the ability to obtain funding for many poorly reimbursed services.

Agents and Patterns of Interaction
Dusty Garden has a dense and diverse web of complex interdependence. During the first few years of our research, most practice staff members came from the community. The practice grew from 4 to 6 family physicians and 2 nurse practitioners, and there was also much staff turnover. Dusty Garden was often a stepping stone for some clinicians, a chance to work in an “idealistic place” before going on to other things. However, the leadership has remained stable.

Local Fitness Landscape
The health care needs in the community were great, and the practice responded by growing rapidly, at times exceeding resources. At the same time, the local market consolidated into 2 competing hospital systems, with nearly all practices officially aligned with one of them. Necessary external funding also became more difficult to obtain.

Regional/Global Influences
Patients were represented by a mix of insurers. Uninsured or underinsured patients were cared for under a sliding-scale reimbursement scheme. There was also a perceived need to demonstrate successes and quality of care, and to place more emphasis on productivity and efficiency.

Self-Organization
The original practice was located in a dusty and cluttered building. It was difficult to tell who was responsible for what, but a shared sense of purpose gave the practice a family feel. Conflicts were evident but quickly resolved by frank discussions and a shared commitment to the practice mission. Schedules were constantly being disrupted by responding to patients and staff members’ diverse needs. In spite of this seeming chaos, Dusty Garden was an exemplar at delivering preventive services. This was accomplished by several dedicated clinicians and practice systems that involved the active participation of multiple personnel.

Co-Evolution
Significant change was occurring, and the practice was pushed to divide or grow in response to increasing patient demand and community need. They chose to grow and move into a much larger, newer, and more functional building down the street, resulting in a set of unanticipated consequences as both they and the fitness landscape changed. The new facility was more accessible and visible to a demographically different set of patients. Because of the changes in the local health care system, Dusty Garden also felt compelled to develop a relationship with the academic hospital system.

Emergence
What emerged was an organization where staff were isolated in large functionally differentiated spaces. The greater practice size demanded more specialization, and patterns of relationships dramatically changed. The change altered the number and specifics of the agents; many of the community-based staff left; and there was frequent turnover among newly hired and overwhelmed front office staff. The change also altered the number and character of the interactions per agent. Still, the vision remains strong, and many meetings are occurring to restore a “new” sense of practice community. Preventive service delivery rates remain high. The leadership initially responded to these changes with efforts aimed at greater standardization, but these are now being balanced by paying more attention to what solutions are being improvised “on the ground.”

Case study analysis

A comparative analysis of these 2 cases provides the following insights based on a complexity science view of the world:

1. Each practice was performing well using the delivery of preventive health and patient satisfaction as proxies for total practice performance.
2. The practices differed from each other in critical ways that seem to be at odds with traditional “best practices” thinking.
3. The practices were similar in that they had each organized themselves, coevolved, and emerged as a function of the nonlinear interdependencies among agents and the local fitness landscape, not solely as a function of some externally imposed script.
4. Each practice engaged in sensemaking activity to understand its unfolding world.
5. Each practice engaged in improvisational behavior as a strategy for developing strategic and tactical responses to its unfolding world.
6. Variation was often a source of strength, not a sign of bad practice.

Discussion

The traditional,^2-4 largely unsubstantiated,^37-40 view is that the best way to improve care is to eliminate variation. A view of family practice informed by complexity science suggests otherwise. In complex adaptive systems, agents in the practices create responses to changing circumstances—they improvise, or play practice jazz. Jazz players are often seen as role models of sensemaking and improvisational behavior.²⁸ They know a general musical structure, and within that they create jazz. Bad jazz occurs when one person plays what the others cannot make sense of and build on. All the players have an interdependent responsibility to create good jazz. When good jazz players hear something unexpected, they make sense of it and improvise. Dealing with the uncertain nature of complex adaptive systems involves thinking in terms of making sense of what is emerging. How can I improvise to use whatever happens to further the system’s development? It involves building on emergent characteristics of the complex adaptive system to develop patterns of social interaction⁴¹ among agents that give them confidence in each other, lead to small wins, and enhance the capacity to learn from unpredicted events.⁴²

Nevertheless, differentiating desirable from undesirable variation is an opportunity to learn from our history, and an opportunity to improve our practice jazz.^37,41,43 Small changes can have large results in some settings, while large efforts may lead to meager results in others. Complexity theory offers a framework for understanding these phenomena in family practice, and lays the groundwork for future research. On the basis of the proposed theoretical model, we hypothesize that it is critical to differentiate the variations that are sources of error from the variations due to the dynamics of relationships. From the perspective of complexity science, relational variation is linked to diversity among agents and represents constructive and adaptive variations and emergent behavior within an ever-changing and unpredictable local fitness landscape. From this perspective, the goals are to eliminate error through development of better systems of operation and to reduce confusion and poor judgment by improving sensemaking and communication. It is also important to enhance desirable variation by developing the skills of the relationship-centered clinical method,^44-46 improvisation, and reflective practice.^47-50

Sensemaking may be enhanced by considering the 4 ways of knowing health and health care,⁵¹ which include understanding: (1) the clinician; (2) the patient, family, and community; (3) systems; and (4) scientific evidence about disease and treatment. Judgments about the variation can be made within each way of knowing. Desirable variation due to clinician factors should build on each clinician’s unique skills and values, and compensate for or improve weaknesses. Local adaptation of objective evidence and the development of unique approaches to meeting the needs of patients in their personal and local context represent potentially desirable sources of variation. Evidence-based medicine provides a basis for reducing variation on the basis of scientific knowledge developed from studies of groups of individuals. Systems that integrate scientific evidence with the unique needs of patients, families, and communities and the specific talents of clinicians represent an opportunity for interventions that both reduce variation from known effective health care approaches and increase variability that personalizes care. Complexity science can help us to look for the inter-relationships among these different ways of knowing and to recognize what is not knowable or controllable. Yet, complexity science represents only a partial answer to efforts to integrate these diverse perspectives. There is a need for additional theoretical work to develop approaches that both include and transcend current ways of thinking.^52,53

Family practices are systems co-evolving within fitness landscapes where there is a continual need for sensemaking and improvisation. This is particularly true during the current period of rapid change and co-evolution of practices with a rapidly changing health care system. Excessive standardization with the goal of trying to maximize each part is as potentially problematic⁵¹ as variation from scientific evidence. Like a healthy body, a healthy practice represents a balance of the generalizable and the particular. The result is tension between the local, the regulatory, and the universal—and between patient, professional, societal, and ecological expectations. We believe the principles of complexity science explain why linear quality improvement interventions (one disease at a time) often have limited effect and poor transportability.^{15,16,19,54-56} These principles may also explain why countries with a higher proportion of primary care services have better population health status^36,57,58 despite the repeated observation that specialists do better at following disease guidelines and improving disease specific outcomes.^59-61 It is never just about the specific; it is about the specific in relation to the whole, and the whole is always more than the sum of the specifics. Good primary care serves all members of the community well with the resources available. Further application of complexity science to understand these paradoxes will require more quality longitudinal data in multiple practices and broad integrative measures of the process and outcomes of care.^51,62

Conclusions

Family physicians are told to implement guidelines, to diagnose and treat in specific ways, and to eliminate variation in practice. Our study using complexity science suggests that this is only part of the story. Family practices are systems that self-organize, reveal emergent behavior, and co-evolve. Successful practices are those that minimize errors, make good sense of what is happening, and effectively improvise to make good practice jazz. Seeking to eliminate error by dampening all variation through the imposition of excessive standardization and external controls is unlikely to be sustainably effective and is likely to have long-term negative consequences. We encourage all family practice staff members to become knowledgeable of practice guidelines and evidence-based practice; these are some of the core skills of good patient care.⁶³ Using these core skills to implement flexible, locally meaningful systems may reduce error. Also, efforts to change and improve future practice are best served by focusing on improving care as a whole and on developing the skills of reflective practice and relationship-centered care.⁵¹ We encourage policymakers to acknowledge the potential benefits of some kinds of variation and to support its healthy evolution.

Acknowledgments

The data used in our paper came from studies supported by a grant (1RO1 HS08776) from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and grants from the National Cancer Institute (1RO1 CA60862 and 2RO1 CA60862). A A grant from the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio, supported communications, analyses, and writing. We are grateful to the practices participating in the research on which our paper was based.

One major focus of health services research and quality improvement efforts is to identify and reduce variation.^1-4 Standardization is the approach usually offered to minimize variation, thus reducing errors and increasing quality.^5,6 These interventions are often based on an industrial quality improvement paradigm⁷ using linear interventions that assume that inputs reliably lead to proportionate responses.⁸ These interventions include re-engineering and expanded information systems.^9,10 If the application of linear Newtonian views is correct, then standardization is the key to quality improvement, and effective practices will look much alike. The search for and attempt to implement best practice guidelines^11-14 are examples of efforts to bring practices into conformity and to establish process standards for best behavior. However, the search for simple, easily transportable interventions has not been as successful as traditional logic might suggest.^15-19

Emerging views of organizations derived from complexity science bring the key understanding that practices are more than commodity-delivering businesses—they are complex adaptive systems.²⁰ These systems involve connected participants interacting in ways that generate the spontaneous emergence of new structures and behaviors. In complex adaptive systems, we expect to see variation in practice patterns, even when the outcomes of practices are similar.

In a previous issue of JFP,²¹ we proposed a model of primary care practices as complex adaptive systems and suggested implications and strategies for change. Since then we have begun applying this theoretical framework to other studies designed to understand and advance generalist practice. Our present purpose is to advance the application of complexity science to understanding and improving primary care practices and their co-evolving health care systems.

The theory application process

The 3 studies that this theory application builds on began with the Direct Observation of Primary Care (DOPC) study, a 3-year (1994-1997) multimethod descriptive investigation of the content of 4454 patient visits to 138 family physicians in 84 family practices.^22,23 One of the outcomes of this study was a model for understanding change in family practice based on complexity science.²¹ Subsequently, The Prevention and Competing Demands in Primary Care Study (PCDPC) was a 3-year (1996-1999) in-depth descriptive case study of 1637 outpatient visits to 56 clinicians in18 family practices purposefully sampled to include diversity in geographic location, size of practice, and intensity of delivery of preventive services.²⁴ We also implemented a 4-year (1997-2001) multimethod clinical trial, the Study to Enhance Prevention by Understanding and Practice (STEP-UP), to understand and improve the delivery of preventive health services in 77 family practices.²⁵

We conducted an explicit theory application and refinement process consisting of 10 meetings to analyze data from DOPC, PCDPC, and STEP-UP, informed by a literature review of complexity science. The developing model was explicitly tested in 3 Nebraska family practices in 1999 in an effort to improve diabetes care.²⁶ The resulting specific theory application to family practices was then evaluated using 2 cases from these studies.

Application of complexity science to family practice

Synthesizing our observations of the family practices and the literature review, we developed the following theoretical model. Family practices are local professional complex adaptive systems with the primary purpose of seeing patients for everyday health concerns to assist “them” in getting on with their daily lives. “Them” refers to the patients and their families, the clinicians, and the office staff. Practice leaders and managers usually describe their practices in terms of efficiency, productivity, adherence to standards of care, and patient satisfaction. Increasingly, practices function in interactive ways with managers or owners from local health care systems. Still, these practices behaved more like complex adaptive systems operating within a professional milieu than like businesses.²⁷

Complex adaptive systems are like a family reunion; they are dynamic-bounded webs of diverse agents interacting nonlinearly.²⁸ Dynamic refers to the continual presence of multiple interactions and their accompanying surprises, challenges, and responses, both within the system and between the system (eg, practices) and its environment. Bounded refers to the defining purpose or intent of the system (eg, to deliver health care to local patients). The metaphor of a web characterizes the multiple interconnections of the system. The agents in practices include clinicians, office staff, and patients, and can also include pharmaceutical representatives, health care system administrators, and others. Agents have the capacity to exchange information, learn, and adjust their behavior. No individual agent can ever know or understand everything that is occurring. The nonlinear relationships among the agents are the result of ongoing feedback loops and mean that small changes can lead to large effects and big changes can lead to small effects. For example, the introduction of a small medical record stamp to identify smokers in one practice leads to a dramatic increase in smoking counseling, while a major quality improvement program in another practice results in minimal change.

What makes an organization “professional” is the application of specialized values and expertise to address difficult problems and uncertainty. These values and skills are acquired through specialized training and are created by the larger social context.²⁹ It is the socially defined professional values and expertise of the family physician that are applied in their daily activities. A co-evolving professional world of the health system and payer manager is increasingly interacting with the physician professional value system.

Each family practice is unique because of 5 features:

1. History and initial conditions,including any explicit or implicit mission and the underlying priorities for the practice.
2. Particular agents and their unique styles and interests.
3. The pattern of nonlinear interactions among agents.
4. The local fitness landscape(ie, the practice’s ecological niche) and its particular expectations, community values, competitive issues, and ecology.
5. Regional and global influences, such as larger health care systems, finances and regulations, and culture.

The local fitness landscape, a complexity science term from evolutionary biology, specifically refers to the local terrain and all the many complex adaptive systems, from microbes to organizations, that seek their own purpose and niche within that terrain. Biological evolution and technological evolution are processes attempting to optimize systems riddled with conflicting constraints.³⁰ Each family practice must evolve by attempting to optimize the entire package of services it delivers. This evolution must account for all the other competing and cooperating health care services and local resources, such as economic conditions, availability of insurance types, and the particular local disease and illness epidemiology.

How all of these factors manifest in a particular family practice at any given time and over time can be understood using 3 complexity science properties: self-organization, emergence, and co-evolution. Self-organization refers to the spontaneous development of structures and forms of behavior in systems characterized by multiple feedback loops and nonlinear dynamics. These structures are a function of the patterns of relationships among agents. Everything changes in response to and as a result of everything else, with each complex adaptive system seeking a better position in its local fitness landscape—a niche where it can prosper and survive.³¹ In this setting of ongoing co-evolution, both competition and collaboration become strategies for workable solutions. As the agents of any complex adaptive system interact, novelty and surprise continuously emerge in unpredictable ways. For example, a new successful approach to scheduling is introduced by an unassuming receptionist. This emergence creates a system that is greater than the sum of its parts; it is what cannot be understood through a reductionist (one problem at a time) examination of the practice.³²

A particular family practice is the unique self-organized system that emerges when particular physicians and staff (agents) come together in particular ways with particular goals, preferences, and priorities (initial conditions) within a particular community setting (local fitness landscape) given specific regional and global influences. At any future point, this practice is the unique self-organized system that has emerged through co-evolution with all the other systems in the local fitness landscape.

The result is much variation between and within family practices. Practices have much in common, however, because of their common goal of seeing patients to assist them with their everyday health problems in a shared cultural and historical context. From that perspective, variation in family practices is inevitable and a powerful source of creative possibility, value, and good clinical practice. Practices use 2 strategies for successfully enhancing that creativity: sensemaking and improvisation. Sensemaking is a social activity that requires interaction among agents.^33,34 People must come to have some notion of “Who am I,” “Why am I here,” and “What is going on around me?” Improvisation is a strategy for dealing with surprise in complex adaptive systems. Improvisation can be described as intuition guiding action in a spontaneous way.³⁵ Intuition is not a random guess at what to do, but the result of using high levels of expertise to act in the moment.^27,36

Among the many practices in the studies we are currently analyzing, multiple areas of variation are observed. These include differences in charting systems, clinical care decisions, scheduling, billing and coding procedures, staff relationships, and management and clinical styles. Sometimes these variations provide an adaptive advantage, but often not, and it is seldom clear in advance which will be true. Inflexible standardization, however, is often poorly responsive to the needs of different practices’ diverse agents and to the almost constant situations of uncertainty, contextual uniqueness, and surprise that occur in the practices.

Case studies

To illustrate the application of complexity science–based sensemaking to family practice, we present 2 case studies.

We selected 2 practices that had high quality of care as measured by delivery of preventive health services and patient satisfaction. One case takes advantage of the longitudinal data from DOPC and STEP-UP, and the other makes use of the more in-depth cross-sectional data from PCDPC. The cases were also selected to assure maximum variation in location and affiliation, and homogeneity in practice size (4-8 clinicians). The names have been changed to protect confidentiality.

Franchise Family Practice

History/Initial Conditions
Franchise is one of several primary care offices created by the Health Salute Corporation in affluent suburban areas of intense competition for market share growth. The corporate intent for this practice is to be productive and profitable. Two family physicians, a pediatrician, and a nurse practitioner were brought in from other practices, and several of their staff members followed. They all agree that their mission is to be the best practice in the Health Salute Corporation. Their identity is to capture market share through better efficiency, a mechanistic approach (scientific and standardized), and a friendly and caring attitude.

Agents and Patterns of Interaction
The practice manager’s daily attire in stockings and heels sets the tone for interactions, which are formal and professional. A small core of staff is dedicated to this practice, but there is often temporary help from other Health Salute offices during busy times. The patient population of predominantly mobile, insured, 2 working parent families tends to value convenience over relationships. The physicians seem to have little emotional investment in this particular practice, place, or each other. Conflicts are minimized and usually covered over with humor.

Local Fitness Landscape
There is no clear sense of community in this new suburb. Franchise is located in the heart of “minivan land,” an unrolling suburban carpet. The 2 competing systems are a major threat and are constantly being discussed. It is very clear that the survival of Franchise is dependent on success in the marketplace as determined by Health Salute.

Regional/Global Influences
Managed care has a strong presence, with much pressure to implement multiple practice guidelines, frequent chart audits, and different formularies.

Self-Organization
In many respects, Franchise Family Practice comes close to fulfilling its mission. Franchise is friendly, fun loving, and clean. It is a high performer at delivering preventive health services and is full of glitz and protocols. There are multiple systems in place for all phases of practice operation, and the manager sees they are working.

Emergence
Despite this managed order, surprises, problems, uncertainty, and complexities keep arising on a daily basis. Occasionally individuals respond creatively, but more often they stick to the protocols and generate even more trouble. There are frequent staff meetings where common problems are discussed. Many different solutions emerge in these discussions, but the final resolution is usually based on what the practice management thinks Health Salute would want. Even in this intensely structured practice, multiple competing demands, power distributions, and interpersonal battles are being simultaneously worked out on a daily basis.

Co-Evolution
As the suburbs grew, more practices were opened. The original practice in the area was soon challenged by Franchise and then by another competitor. Each of the 3 practices often acted or reacted in response to the others. Approximately a year after our research ended, Franchise Family Practice was closed by Health Salute because of inadequate profitability, and within a few months the second competitor also closed its practice.

Dusty Garden Family Practice

History/Initial Conditions
Dusty Garden began as a pioneering model for community-oriented primary care in an economically impoverished urban area. The practice was created with a focus on the patient in this underserved community. Envisioned by its founding family physician and practice manager, this practice was established in close collaboration with a community board. Survival is dependent on the ability to obtain funding for many poorly reimbursed services.

Agents and Patterns of Interaction
Dusty Garden has a dense and diverse web of complex interdependence. During the first few years of our research, most practice staff members came from the community. The practice grew from 4 to 6 family physicians and 2 nurse practitioners, and there was also much staff turnover. Dusty Garden was often a stepping stone for some clinicians, a chance to work in an “idealistic place” before going on to other things. However, the leadership has remained stable.

Local Fitness Landscape
The health care needs in the community were great, and the practice responded by growing rapidly, at times exceeding resources. At the same time, the local market consolidated into 2 competing hospital systems, with nearly all practices officially aligned with one of them. Necessary external funding also became more difficult to obtain.

Regional/Global Influences
Patients were represented by a mix of insurers. Uninsured or underinsured patients were cared for under a sliding-scale reimbursement scheme. There was also a perceived need to demonstrate successes and quality of care, and to place more emphasis on productivity and efficiency.

Self-Organization
The original practice was located in a dusty and cluttered building. It was difficult to tell who was responsible for what, but a shared sense of purpose gave the practice a family feel. Conflicts were evident but quickly resolved by frank discussions and a shared commitment to the practice mission. Schedules were constantly being disrupted by responding to patients and staff members’ diverse needs. In spite of this seeming chaos, Dusty Garden was an exemplar at delivering preventive services. This was accomplished by several dedicated clinicians and practice systems that involved the active participation of multiple personnel.

Co-Evolution
Significant change was occurring, and the practice was pushed to divide or grow in response to increasing patient demand and community need. They chose to grow and move into a much larger, newer, and more functional building down the street, resulting in a set of unanticipated consequences as both they and the fitness landscape changed. The new facility was more accessible and visible to a demographically different set of patients. Because of the changes in the local health care system, Dusty Garden also felt compelled to develop a relationship with the academic hospital system.

Emergence
What emerged was an organization where staff were isolated in large functionally differentiated spaces. The greater practice size demanded more specialization, and patterns of relationships dramatically changed. The change altered the number and specifics of the agents; many of the community-based staff left; and there was frequent turnover among newly hired and overwhelmed front office staff. The change also altered the number and character of the interactions per agent. Still, the vision remains strong, and many meetings are occurring to restore a “new” sense of practice community. Preventive service delivery rates remain high. The leadership initially responded to these changes with efforts aimed at greater standardization, but these are now being balanced by paying more attention to what solutions are being improvised “on the ground.”

Case study analysis

A comparative analysis of these 2 cases provides the following insights based on a complexity science view of the world:

1. Each practice was performing well using the delivery of preventive health and patient satisfaction as proxies for total practice performance.
2. The practices differed from each other in critical ways that seem to be at odds with traditional “best practices” thinking.
3. The practices were similar in that they had each organized themselves, coevolved, and emerged as a function of the nonlinear interdependencies among agents and the local fitness landscape, not solely as a function of some externally imposed script.
4. Each practice engaged in sensemaking activity to understand its unfolding world.
5. Each practice engaged in improvisational behavior as a strategy for developing strategic and tactical responses to its unfolding world.
6. Variation was often a source of strength, not a sign of bad practice.

Discussion

The traditional,^2-4 largely unsubstantiated,^37-40 view is that the best way to improve care is to eliminate variation. A view of family practice informed by complexity science suggests otherwise. In complex adaptive systems, agents in the practices create responses to changing circumstances—they improvise, or play practice jazz. Jazz players are often seen as role models of sensemaking and improvisational behavior.²⁸ They know a general musical structure, and within that they create jazz. Bad jazz occurs when one person plays what the others cannot make sense of and build on. All the players have an interdependent responsibility to create good jazz. When good jazz players hear something unexpected, they make sense of it and improvise. Dealing with the uncertain nature of complex adaptive systems involves thinking in terms of making sense of what is emerging. How can I improvise to use whatever happens to further the system’s development? It involves building on emergent characteristics of the complex adaptive system to develop patterns of social interaction⁴¹ among agents that give them confidence in each other, lead to small wins, and enhance the capacity to learn from unpredicted events.⁴²

Nevertheless, differentiating desirable from undesirable variation is an opportunity to learn from our history, and an opportunity to improve our practice jazz.^37,41,43 Small changes can have large results in some settings, while large efforts may lead to meager results in others. Complexity theory offers a framework for understanding these phenomena in family practice, and lays the groundwork for future research. On the basis of the proposed theoretical model, we hypothesize that it is critical to differentiate the variations that are sources of error from the variations due to the dynamics of relationships. From the perspective of complexity science, relational variation is linked to diversity among agents and represents constructive and adaptive variations and emergent behavior within an ever-changing and unpredictable local fitness landscape. From this perspective, the goals are to eliminate error through development of better systems of operation and to reduce confusion and poor judgment by improving sensemaking and communication. It is also important to enhance desirable variation by developing the skills of the relationship-centered clinical method,^44-46 improvisation, and reflective practice.^47-50

Sensemaking may be enhanced by considering the 4 ways of knowing health and health care,⁵¹ which include understanding: (1) the clinician; (2) the patient, family, and community; (3) systems; and (4) scientific evidence about disease and treatment. Judgments about the variation can be made within each way of knowing. Desirable variation due to clinician factors should build on each clinician’s unique skills and values, and compensate for or improve weaknesses. Local adaptation of objective evidence and the development of unique approaches to meeting the needs of patients in their personal and local context represent potentially desirable sources of variation. Evidence-based medicine provides a basis for reducing variation on the basis of scientific knowledge developed from studies of groups of individuals. Systems that integrate scientific evidence with the unique needs of patients, families, and communities and the specific talents of clinicians represent an opportunity for interventions that both reduce variation from known effective health care approaches and increase variability that personalizes care. Complexity science can help us to look for the inter-relationships among these different ways of knowing and to recognize what is not knowable or controllable. Yet, complexity science represents only a partial answer to efforts to integrate these diverse perspectives. There is a need for additional theoretical work to develop approaches that both include and transcend current ways of thinking.^52,53

Family practices are systems co-evolving within fitness landscapes where there is a continual need for sensemaking and improvisation. This is particularly true during the current period of rapid change and co-evolution of practices with a rapidly changing health care system. Excessive standardization with the goal of trying to maximize each part is as potentially problematic⁵¹ as variation from scientific evidence. Like a healthy body, a healthy practice represents a balance of the generalizable and the particular. The result is tension between the local, the regulatory, and the universal—and between patient, professional, societal, and ecological expectations. We believe the principles of complexity science explain why linear quality improvement interventions (one disease at a time) often have limited effect and poor transportability.^{15,16,19,54-56} These principles may also explain why countries with a higher proportion of primary care services have better population health status^36,57,58 despite the repeated observation that specialists do better at following disease guidelines and improving disease specific outcomes.^59-61 It is never just about the specific; it is about the specific in relation to the whole, and the whole is always more than the sum of the specifics. Good primary care serves all members of the community well with the resources available. Further application of complexity science to understand these paradoxes will require more quality longitudinal data in multiple practices and broad integrative measures of the process and outcomes of care.^51,62

Conclusions

Family physicians are told to implement guidelines, to diagnose and treat in specific ways, and to eliminate variation in practice. Our study using complexity science suggests that this is only part of the story. Family practices are systems that self-organize, reveal emergent behavior, and co-evolve. Successful practices are those that minimize errors, make good sense of what is happening, and effectively improvise to make good practice jazz. Seeking to eliminate error by dampening all variation through the imposition of excessive standardization and external controls is unlikely to be sustainably effective and is likely to have long-term negative consequences. We encourage all family practice staff members to become knowledgeable of practice guidelines and evidence-based practice; these are some of the core skills of good patient care.⁶³ Using these core skills to implement flexible, locally meaningful systems may reduce error. Also, efforts to change and improve future practice are best served by focusing on improving care as a whole and on developing the skills of reflective practice and relationship-centered care.⁵¹ We encourage policymakers to acknowledge the potential benefits of some kinds of variation and to support its healthy evolution.

Acknowledgments

The data used in our paper came from studies supported by a grant (1RO1 HS08776) from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and grants from the National Cancer Institute (1RO1 CA60862 and 2RO1 CA60862). A A grant from the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio, supported communications, analyses, and writing. We are grateful to the practices participating in the research on which our paper was based.

One major focus of health services research and quality improvement efforts is to identify and reduce variation.^1-4 Standardization is the approach usually offered to minimize variation, thus reducing errors and increasing quality.^5,6 These interventions are often based on an industrial quality improvement paradigm⁷ using linear interventions that assume that inputs reliably lead to proportionate responses.⁸ These interventions include re-engineering and expanded information systems.^9,10 If the application of linear Newtonian views is correct, then standardization is the key to quality improvement, and effective practices will look much alike. The search for and attempt to implement best practice guidelines^11-14 are examples of efforts to bring practices into conformity and to establish process standards for best behavior. However, the search for simple, easily transportable interventions has not been as successful as traditional logic might suggest.^15-19

Emerging views of organizations derived from complexity science bring the key understanding that practices are more than commodity-delivering businesses—they are complex adaptive systems.²⁰ These systems involve connected participants interacting in ways that generate the spontaneous emergence of new structures and behaviors. In complex adaptive systems, we expect to see variation in practice patterns, even when the outcomes of practices are similar.

In a previous issue of JFP,²¹ we proposed a model of primary care practices as complex adaptive systems and suggested implications and strategies for change. Since then we have begun applying this theoretical framework to other studies designed to understand and advance generalist practice. Our present purpose is to advance the application of complexity science to understanding and improving primary care practices and their co-evolving health care systems.

The theory application process

The 3 studies that this theory application builds on began with the Direct Observation of Primary Care (DOPC) study, a 3-year (1994-1997) multimethod descriptive investigation of the content of 4454 patient visits to 138 family physicians in 84 family practices.^22,23 One of the outcomes of this study was a model for understanding change in family practice based on complexity science.²¹ Subsequently, The Prevention and Competing Demands in Primary Care Study (PCDPC) was a 3-year (1996-1999) in-depth descriptive case study of 1637 outpatient visits to 56 clinicians in18 family practices purposefully sampled to include diversity in geographic location, size of practice, and intensity of delivery of preventive services.²⁴ We also implemented a 4-year (1997-2001) multimethod clinical trial, the Study to Enhance Prevention by Understanding and Practice (STEP-UP), to understand and improve the delivery of preventive health services in 77 family practices.²⁵

We conducted an explicit theory application and refinement process consisting of 10 meetings to analyze data from DOPC, PCDPC, and STEP-UP, informed by a literature review of complexity science. The developing model was explicitly tested in 3 Nebraska family practices in 1999 in an effort to improve diabetes care.²⁶ The resulting specific theory application to family practices was then evaluated using 2 cases from these studies.

Application of complexity science to family practice

Synthesizing our observations of the family practices and the literature review, we developed the following theoretical model. Family practices are local professional complex adaptive systems with the primary purpose of seeing patients for everyday health concerns to assist “them” in getting on with their daily lives. “Them” refers to the patients and their families, the clinicians, and the office staff. Practice leaders and managers usually describe their practices in terms of efficiency, productivity, adherence to standards of care, and patient satisfaction. Increasingly, practices function in interactive ways with managers or owners from local health care systems. Still, these practices behaved more like complex adaptive systems operating within a professional milieu than like businesses.²⁷

Complex adaptive systems are like a family reunion; they are dynamic-bounded webs of diverse agents interacting nonlinearly.²⁸ Dynamic refers to the continual presence of multiple interactions and their accompanying surprises, challenges, and responses, both within the system and between the system (eg, practices) and its environment. Bounded refers to the defining purpose or intent of the system (eg, to deliver health care to local patients). The metaphor of a web characterizes the multiple interconnections of the system. The agents in practices include clinicians, office staff, and patients, and can also include pharmaceutical representatives, health care system administrators, and others. Agents have the capacity to exchange information, learn, and adjust their behavior. No individual agent can ever know or understand everything that is occurring. The nonlinear relationships among the agents are the result of ongoing feedback loops and mean that small changes can lead to large effects and big changes can lead to small effects. For example, the introduction of a small medical record stamp to identify smokers in one practice leads to a dramatic increase in smoking counseling, while a major quality improvement program in another practice results in minimal change.

What makes an organization “professional” is the application of specialized values and expertise to address difficult problems and uncertainty. These values and skills are acquired through specialized training and are created by the larger social context.²⁹ It is the socially defined professional values and expertise of the family physician that are applied in their daily activities. A co-evolving professional world of the health system and payer manager is increasingly interacting with the physician professional value system.

Each family practice is unique because of 5 features:

1. History and initial conditions,including any explicit or implicit mission and the underlying priorities for the practice.
2. Particular agents and their unique styles and interests.
3. The pattern of nonlinear interactions among agents.
4. The local fitness landscape(ie, the practice’s ecological niche) and its particular expectations, community values, competitive issues, and ecology.
5. Regional and global influences, such as larger health care systems, finances and regulations, and culture.

The local fitness landscape, a complexity science term from evolutionary biology, specifically refers to the local terrain and all the many complex adaptive systems, from microbes to organizations, that seek their own purpose and niche within that terrain. Biological evolution and technological evolution are processes attempting to optimize systems riddled with conflicting constraints.³⁰ Each family practice must evolve by attempting to optimize the entire package of services it delivers. This evolution must account for all the other competing and cooperating health care services and local resources, such as economic conditions, availability of insurance types, and the particular local disease and illness epidemiology.

How all of these factors manifest in a particular family practice at any given time and over time can be understood using 3 complexity science properties: self-organization, emergence, and co-evolution. Self-organization refers to the spontaneous development of structures and forms of behavior in systems characterized by multiple feedback loops and nonlinear dynamics. These structures are a function of the patterns of relationships among agents. Everything changes in response to and as a result of everything else, with each complex adaptive system seeking a better position in its local fitness landscape—a niche where it can prosper and survive.³¹ In this setting of ongoing co-evolution, both competition and collaboration become strategies for workable solutions. As the agents of any complex adaptive system interact, novelty and surprise continuously emerge in unpredictable ways. For example, a new successful approach to scheduling is introduced by an unassuming receptionist. This emergence creates a system that is greater than the sum of its parts; it is what cannot be understood through a reductionist (one problem at a time) examination of the practice.³²

A particular family practice is the unique self-organized system that emerges when particular physicians and staff (agents) come together in particular ways with particular goals, preferences, and priorities (initial conditions) within a particular community setting (local fitness landscape) given specific regional and global influences. At any future point, this practice is the unique self-organized system that has emerged through co-evolution with all the other systems in the local fitness landscape.

The result is much variation between and within family practices. Practices have much in common, however, because of their common goal of seeing patients to assist them with their everyday health problems in a shared cultural and historical context. From that perspective, variation in family practices is inevitable and a powerful source of creative possibility, value, and good clinical practice. Practices use 2 strategies for successfully enhancing that creativity: sensemaking and improvisation. Sensemaking is a social activity that requires interaction among agents.^33,34 People must come to have some notion of “Who am I,” “Why am I here,” and “What is going on around me?” Improvisation is a strategy for dealing with surprise in complex adaptive systems. Improvisation can be described as intuition guiding action in a spontaneous way.³⁵ Intuition is not a random guess at what to do, but the result of using high levels of expertise to act in the moment.^27,36

Among the many practices in the studies we are currently analyzing, multiple areas of variation are observed. These include differences in charting systems, clinical care decisions, scheduling, billing and coding procedures, staff relationships, and management and clinical styles. Sometimes these variations provide an adaptive advantage, but often not, and it is seldom clear in advance which will be true. Inflexible standardization, however, is often poorly responsive to the needs of different practices’ diverse agents and to the almost constant situations of uncertainty, contextual uniqueness, and surprise that occur in the practices.

Case studies

To illustrate the application of complexity science–based sensemaking to family practice, we present 2 case studies.

We selected 2 practices that had high quality of care as measured by delivery of preventive health services and patient satisfaction. One case takes advantage of the longitudinal data from DOPC and STEP-UP, and the other makes use of the more in-depth cross-sectional data from PCDPC. The cases were also selected to assure maximum variation in location and affiliation, and homogeneity in practice size (4-8 clinicians). The names have been changed to protect confidentiality.

Franchise Family Practice

History/Initial Conditions
Franchise is one of several primary care offices created by the Health Salute Corporation in affluent suburban areas of intense competition for market share growth. The corporate intent for this practice is to be productive and profitable. Two family physicians, a pediatrician, and a nurse practitioner were brought in from other practices, and several of their staff members followed. They all agree that their mission is to be the best practice in the Health Salute Corporation. Their identity is to capture market share through better efficiency, a mechanistic approach (scientific and standardized), and a friendly and caring attitude.

Agents and Patterns of Interaction
The practice manager’s daily attire in stockings and heels sets the tone for interactions, which are formal and professional. A small core of staff is dedicated to this practice, but there is often temporary help from other Health Salute offices during busy times. The patient population of predominantly mobile, insured, 2 working parent families tends to value convenience over relationships. The physicians seem to have little emotional investment in this particular practice, place, or each other. Conflicts are minimized and usually covered over with humor.

Local Fitness Landscape
There is no clear sense of community in this new suburb. Franchise is located in the heart of “minivan land,” an unrolling suburban carpet. The 2 competing systems are a major threat and are constantly being discussed. It is very clear that the survival of Franchise is dependent on success in the marketplace as determined by Health Salute.

Regional/Global Influences
Managed care has a strong presence, with much pressure to implement multiple practice guidelines, frequent chart audits, and different formularies.

Self-Organization
In many respects, Franchise Family Practice comes close to fulfilling its mission. Franchise is friendly, fun loving, and clean. It is a high performer at delivering preventive health services and is full of glitz and protocols. There are multiple systems in place for all phases of practice operation, and the manager sees they are working.

Emergence
Despite this managed order, surprises, problems, uncertainty, and complexities keep arising on a daily basis. Occasionally individuals respond creatively, but more often they stick to the protocols and generate even more trouble. There are frequent staff meetings where common problems are discussed. Many different solutions emerge in these discussions, but the final resolution is usually based on what the practice management thinks Health Salute would want. Even in this intensely structured practice, multiple competing demands, power distributions, and interpersonal battles are being simultaneously worked out on a daily basis.

Co-Evolution
As the suburbs grew, more practices were opened. The original practice in the area was soon challenged by Franchise and then by another competitor. Each of the 3 practices often acted or reacted in response to the others. Approximately a year after our research ended, Franchise Family Practice was closed by Health Salute because of inadequate profitability, and within a few months the second competitor also closed its practice.

Dusty Garden Family Practice

History/Initial Conditions
Dusty Garden began as a pioneering model for community-oriented primary care in an economically impoverished urban area. The practice was created with a focus on the patient in this underserved community. Envisioned by its founding family physician and practice manager, this practice was established in close collaboration with a community board. Survival is dependent on the ability to obtain funding for many poorly reimbursed services.

Agents and Patterns of Interaction
Dusty Garden has a dense and diverse web of complex interdependence. During the first few years of our research, most practice staff members came from the community. The practice grew from 4 to 6 family physicians and 2 nurse practitioners, and there was also much staff turnover. Dusty Garden was often a stepping stone for some clinicians, a chance to work in an “idealistic place” before going on to other things. However, the leadership has remained stable.

Local Fitness Landscape
The health care needs in the community were great, and the practice responded by growing rapidly, at times exceeding resources. At the same time, the local market consolidated into 2 competing hospital systems, with nearly all practices officially aligned with one of them. Necessary external funding also became more difficult to obtain.

Regional/Global Influences
Patients were represented by a mix of insurers. Uninsured or underinsured patients were cared for under a sliding-scale reimbursement scheme. There was also a perceived need to demonstrate successes and quality of care, and to place more emphasis on productivity and efficiency.

Self-Organization
The original practice was located in a dusty and cluttered building. It was difficult to tell who was responsible for what, but a shared sense of purpose gave the practice a family feel. Conflicts were evident but quickly resolved by frank discussions and a shared commitment to the practice mission. Schedules were constantly being disrupted by responding to patients and staff members’ diverse needs. In spite of this seeming chaos, Dusty Garden was an exemplar at delivering preventive services. This was accomplished by several dedicated clinicians and practice systems that involved the active participation of multiple personnel.

Co-Evolution
Significant change was occurring, and the practice was pushed to divide or grow in response to increasing patient demand and community need. They chose to grow and move into a much larger, newer, and more functional building down the street, resulting in a set of unanticipated consequences as both they and the fitness landscape changed. The new facility was more accessible and visible to a demographically different set of patients. Because of the changes in the local health care system, Dusty Garden also felt compelled to develop a relationship with the academic hospital system.

Emergence
What emerged was an organization where staff were isolated in large functionally differentiated spaces. The greater practice size demanded more specialization, and patterns of relationships dramatically changed. The change altered the number and specifics of the agents; many of the community-based staff left; and there was frequent turnover among newly hired and overwhelmed front office staff. The change also altered the number and character of the interactions per agent. Still, the vision remains strong, and many meetings are occurring to restore a “new” sense of practice community. Preventive service delivery rates remain high. The leadership initially responded to these changes with efforts aimed at greater standardization, but these are now being balanced by paying more attention to what solutions are being improvised “on the ground.”

Case study analysis

A comparative analysis of these 2 cases provides the following insights based on a complexity science view of the world:

1. Each practice was performing well using the delivery of preventive health and patient satisfaction as proxies for total practice performance.
2. The practices differed from each other in critical ways that seem to be at odds with traditional “best practices” thinking.
3. The practices were similar in that they had each organized themselves, coevolved, and emerged as a function of the nonlinear interdependencies among agents and the local fitness landscape, not solely as a function of some externally imposed script.
4. Each practice engaged in sensemaking activity to understand its unfolding world.
5. Each practice engaged in improvisational behavior as a strategy for developing strategic and tactical responses to its unfolding world.
6. Variation was often a source of strength, not a sign of bad practice.

Discussion

The traditional,^2-4 largely unsubstantiated,^37-40 view is that the best way to improve care is to eliminate variation. A view of family practice informed by complexity science suggests otherwise. In complex adaptive systems, agents in the practices create responses to changing circumstances—they improvise, or play practice jazz. Jazz players are often seen as role models of sensemaking and improvisational behavior.²⁸ They know a general musical structure, and within that they create jazz. Bad jazz occurs when one person plays what the others cannot make sense of and build on. All the players have an interdependent responsibility to create good jazz. When good jazz players hear something unexpected, they make sense of it and improvise. Dealing with the uncertain nature of complex adaptive systems involves thinking in terms of making sense of what is emerging. How can I improvise to use whatever happens to further the system’s development? It involves building on emergent characteristics of the complex adaptive system to develop patterns of social interaction⁴¹ among agents that give them confidence in each other, lead to small wins, and enhance the capacity to learn from unpredicted events.⁴²

Nevertheless, differentiating desirable from undesirable variation is an opportunity to learn from our history, and an opportunity to improve our practice jazz.^37,41,43 Small changes can have large results in some settings, while large efforts may lead to meager results in others. Complexity theory offers a framework for understanding these phenomena in family practice, and lays the groundwork for future research. On the basis of the proposed theoretical model, we hypothesize that it is critical to differentiate the variations that are sources of error from the variations due to the dynamics of relationships. From the perspective of complexity science, relational variation is linked to diversity among agents and represents constructive and adaptive variations and emergent behavior within an ever-changing and unpredictable local fitness landscape. From this perspective, the goals are to eliminate error through development of better systems of operation and to reduce confusion and poor judgment by improving sensemaking and communication. It is also important to enhance desirable variation by developing the skills of the relationship-centered clinical method,^44-46 improvisation, and reflective practice.^47-50

Sensemaking may be enhanced by considering the 4 ways of knowing health and health care,⁵¹ which include understanding: (1) the clinician; (2) the patient, family, and community; (3) systems; and (4) scientific evidence about disease and treatment. Judgments about the variation can be made within each way of knowing. Desirable variation due to clinician factors should build on each clinician’s unique skills and values, and compensate for or improve weaknesses. Local adaptation of objective evidence and the development of unique approaches to meeting the needs of patients in their personal and local context represent potentially desirable sources of variation. Evidence-based medicine provides a basis for reducing variation on the basis of scientific knowledge developed from studies of groups of individuals. Systems that integrate scientific evidence with the unique needs of patients, families, and communities and the specific talents of clinicians represent an opportunity for interventions that both reduce variation from known effective health care approaches and increase variability that personalizes care. Complexity science can help us to look for the inter-relationships among these different ways of knowing and to recognize what is not knowable or controllable. Yet, complexity science represents only a partial answer to efforts to integrate these diverse perspectives. There is a need for additional theoretical work to develop approaches that both include and transcend current ways of thinking.^52,53

Family practices are systems co-evolving within fitness landscapes where there is a continual need for sensemaking and improvisation. This is particularly true during the current period of rapid change and co-evolution of practices with a rapidly changing health care system. Excessive standardization with the goal of trying to maximize each part is as potentially problematic⁵¹ as variation from scientific evidence. Like a healthy body, a healthy practice represents a balance of the generalizable and the particular. The result is tension between the local, the regulatory, and the universal—and between patient, professional, societal, and ecological expectations. We believe the principles of complexity science explain why linear quality improvement interventions (one disease at a time) often have limited effect and poor transportability.^{15,16,19,54-56} These principles may also explain why countries with a higher proportion of primary care services have better population health status^36,57,58 despite the repeated observation that specialists do better at following disease guidelines and improving disease specific outcomes.^59-61 It is never just about the specific; it is about the specific in relation to the whole, and the whole is always more than the sum of the specifics. Good primary care serves all members of the community well with the resources available. Further application of complexity science to understand these paradoxes will require more quality longitudinal data in multiple practices and broad integrative measures of the process and outcomes of care.^51,62

Conclusions

Family physicians are told to implement guidelines, to diagnose and treat in specific ways, and to eliminate variation in practice. Our study using complexity science suggests that this is only part of the story. Family practices are systems that self-organize, reveal emergent behavior, and co-evolve. Successful practices are those that minimize errors, make good sense of what is happening, and effectively improvise to make good practice jazz. Seeking to eliminate error by dampening all variation through the imposition of excessive standardization and external controls is unlikely to be sustainably effective and is likely to have long-term negative consequences. We encourage all family practice staff members to become knowledgeable of practice guidelines and evidence-based practice; these are some of the core skills of good patient care.⁶³ Using these core skills to implement flexible, locally meaningful systems may reduce error. Also, efforts to change and improve future practice are best served by focusing on improving care as a whole and on developing the skills of reflective practice and relationship-centered care.⁵¹ We encourage policymakers to acknowledge the potential benefits of some kinds of variation and to support its healthy evolution.

Acknowledgments

The data used in our paper came from studies supported by a grant (1RO1 HS08776) from the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) and grants from the National Cancer Institute (1RO1 CA60862 and 2RO1 CA60862). A A grant from the Center for Research in Family Practice and Primary Care, Cleveland, New Brunswick, Allentown, and San Antonio, supported communications, analyses, and writing. We are grateful to the practices participating in the research on which our paper was based.