Complexity in practice: understanding primary care as a complexadaptive system

BACKGROUND: This series summarises new empirical research on quality improvement through case studies of the implementation of clinical governance arrangements in two primary care organisations (PCOs). OBJECTIVE: To describe a new socio-technical model for effective quality improvement and clinical governance. METHOD: The research strategy included a literature review, survey, in-depth interviews, participant observation and purposively sampled case studies, conducted within a social constructionist ontological perspective. This approach contextualises the origins of clinical governance and the trend towards collaborative partnerships and federated models of practice, enabled by developments in primary care informatics. RESULTS: People operating within multidisciplinary networks communicate with each other to determine actions that govern their most relevant concerns. Quality improvement in two PCOs is enabled through social interactions between individuals and groups with complex relationships; and information technology (IT) systems which make some aspects of the quality of care explicit. CONCLUSIONS: The results are real-world exemplars of the emergent properties of complex adaptive systems. Improving clinical governance in primary care requires both complex social interactions and underpinning informatics. The socio-technical lessons learned from this research should inform future management approaches.