Practice Jazz: Understanding Variation in Family Practices Using Complexity Science

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.