Accepting complexity, creating order : using complexity theory as a lens through which to understand limitations of target-based quality improvement approaches in primary care, and to design interventions for the future : a thesis presented in partial fulfilment of the requirements for the Masters of Quality Systems at Massey University New Zealand, Manawatū, New Zealand
A strong primary care system is essential for improving health outcomes, and Quality Improvement (QI) science and methodologies are seen as useful approaches for reducing variation in outcomes. QI science has its origins in industrial settings dominated by mechanistic, linear approaches. By contrast, health care (including primary care), is increasingly being understood through the lens of complexity science, as a complex, non linear system, or more specifically a Complex Adaptive System (CAS). In order to design QI approaches that work in health care understanding the interaction between the system and a QI approach and matching the approach to the environment is important. This exploratory research utilised a complexity lens as a worldview or metaphor in which to gain an insight into General Practitioner (GP) views of Target Based Performance Programmes (TBPP), as an example of a current QI approach. The aim was to understand if viewing primary care as a CAS could explain limitations of a TBPP approach, and if the same lens could offer ways to adapt and improve QI programmes in primary care, and in complex systems more broadly. More specifically the research aimed to understand if there was a relationship between complexity of problems (which were the focus of a TBPP), and how effective GPs believed the targets were, as well as whether there was a relationship between the complexity and their engagement in achieving targets. A philosophy of pragmatism was applied in designing the research. The epistemology and methodology (research design and methods) applied in this research were positivist in nature. The research tool used was a single-stage exploratory survey. The participants of the research were GPs. There were 27 surveys used in the analysis, which while small provided rich insight. Quantitative methods were used to analyse the data, with qualitative data providing detail to themes. The main findings of this research are that there is a relationship between how complex a problem is perceived to be by GPs, and the extent to which targets are believed to be a good QI approach. Targets where the problem-in-focus is understood as complex, are less likely to be seen as an appropriate approach. To a lesser extent there is also a relationship between increased engagement and decreased complexity. More generally the research suggests there may be a negative relationship between target-based approaches and engagement. Complexity is only one component that needs to be considered in developing QI approaches in primary care; strength of evidence, adequate resourcing, knowledge of QI methods, and consideration of social determinants were also highlighted. This research has shown that a complexity lens provides useful insight into the health system, and that Cynefin, or similar, as a framework for matching problems to approaches could be a useful tool to support and augment QI approaches in primary care. While this research specifically focusses on health care as a CAS, the discussion, approach and findings may be applicable when considering other systems or organisations which can be viewed as displaying characteristics of CAS.