title: How to manage organisational change and create practice teams: experiences of a South African primary care health centre.
abstract: BACKGROUND
  In South Africa, first-contact primary care is delivered by nurses in small clinics and larger community health centres (CHC). CHCs also employ doctors, who often work in isolation from the nurses, with poor differentiation of roles and little effective teamwork or communication. Worcester CHC, a typical public sector CHC in rural South Africa, decided to explore how to create more successful practice teams of doctors and nurses. This paper is based on their experience of both unsuccessful and successful attempts to introduce practice teams and reports on their learning regarding organisational change.
  
  
  METHODS
  An emergent action research study design utilised a co-operative inquiry group. The first nine months of inquiry focused on understanding the initial unsuccessful attempt to create practice teams. This paper reports primarily on the subsequent nine months (four cycles of planning, action, observation and reflection) during which practice teams were re-introduced. The central question was how more effective practice teams of doctors and nurses could be created. The group utilised outcome mapping to assist with planning, monitoring and evaluation. Outcome mapping defined a vision, mission, boundary partners, outcome challenges, progress markers and strategies for the desired changes and supported quantitative monitoring of the process. Qualitative data were derived from the co-operative inquiry group (CIG) meetings and interviews with doctors, nurses, practice teams and patients.
  
  
  RESULTS
  The CIG engaged effectively with 68% of the planned strategies, and more than 60% of the progress markers were achieved for clinical nurse practitioners, doctors, support staff and managers, but not for patients. Key themes that emerged from the inquiry group's reflection on their experience of the change process dealt with the amount of interaction, type of communication, team resilience, staff satisfaction, leadership style, reflective capacity, experimentation and evolution of new structures.
  
  
  CONCLUSIONS
  The group's learning supported a view of change that sees the organisation as a living system in which information flow, participation and the development of resilience are key aspects. These themes fit well into an understanding of change based on complexity theory. If managers of the health system wish to enhance organisational change, then their goal may need to shift from optimising health care delivery in a mechanistic model to optimising health care workers in a living system.
authors.affiliation: Stellenbosch University, Tygerberg, South Africa. rm@sun.ac.za
authors.forename: B J
authors.initials: BJ
authors.lastname: Mash
authors.forename: P
authors.initials: P
authors.lastname: Mayers
authors.forename: H
authors.initials: H
authors.lastname: Conradie
authors.forename: A
authors.initials: A
authors.lastname: Orayn
authors.forename: M
authors.initials: M
authors.lastname: Kuiper
authors.forename: J
authors.initials: J
authors.lastname: Marais
mesh_terms: D006302:Health Services Research; D006801:Humans; D007400:Interprofessional Relations; D007588:Job Satisfaction; D007857:Leadership; D015279:Organizational Culture; D009936:Organizational Innovation; D010348:Patient Care Team / Q000458:organization & administration* / Q000639:trends; D011320:Primary Health Care / Q000458:organization & administration* / Q000639:trends; D036301:Qualitative Research; D013019:South Africa