title: Primary care practice transformation is hard work: insights from a 15-year developmental program of research.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Family Medicine, Robert Wood Johnson Medical School, Somerset, NJ 08873, USA. Crabtrbf@umdnj.edu
authors.forename: Benjamin F
authors.initials: BF
authors.lastname: Crabtree
authors.forename: Paul A
authors.initials: PA
authors.lastname: Nutting
authors.forename: William L
authors.initials: WL
authors.lastname: Miller
authors.forename: Reuben R
authors.initials: RR
authors.lastname: McDaniel
authors.forename: Kurt C
authors.initials: KC
authors.lastname: Stange
authors.forename: Carlos Roberto
authors.initials: CR
authors.lastname: Jaen
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Stewart
mesh_terms: D019058:Community Networks / Q000458:organization & administration; D006302:Health Services Research / Q000458:organization & administration; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D018802:Patient-Centered Care / Q000458:organization & administration*; D010818:Practice Patterns, Physicians' / Q000458:organization & administration*; D011314:Preventive Health Services / Q000458:organization & administration; D011320:Primary Health Care / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration*; D014481:United States