Improving Quality in a Complex Primary Care System -- An Example of
Refugee Care and Literature Review
Rationale, aims and objectives. Applying traditional industrial Quality
Improvement (QI) methodologies to primary care is often inappropriate
because primary care is best thought of as a network of highly
interconnected agents in a complex adaptive system (CAS) that is
particularly responsive to bottom-up rather than top-down management
approaches. We report on a demonstration case study of improvements made
in the Family Health Center (FHC) of the JPS Health Network in a refugee
patient population that illustrate features of QI in a CAS framework as
opposed to a traditional QI approach. Methods. We report on changes in
health system utilization by new refugee patients of the FHC from
2016-2017 and summarize relevant theoretical understandings of quality
management in complex adaptive systems. Results. Applying CAS principles
in the FHC, utilization of the Emergency Department and Urgent Care by
newly arrived refugee patients before their first clinic visit was
reduced by more than half (total visits decreased from 31% to 14% of
the refugee patients). Our review of the literature demonstrates that
traditional top-down QI processes are most often unsuccessful in
improving even a few single-disease metrics, and increases clinician
burnout and penalizes clinicians who care for vulnerable patients.
Improvement in a CAS occurs when front-line clinicians identify care
gaps and are given the flexibility to learn and self-organize to enable
new care processes to emerge, which are created from bottom-up
leadership that utilize existing interdependencies made more sustainable
as front-line clinicians use sensemaking to improve care processes.
Conclusions and future directions. Recent reforms announced in primary
care in Scotland, a few examples in the medical literature, and
statements from some healthcare system leaders are examples of early
adapters who are applying the principles of CAS to their QI efforts.
Such initiatives and our example provide models for others to follow.