Practice Jazz: Understanding Variation in Family Practices Using Complexity Science

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