Evolving through Multiple, Co-Existing Pressures to Change: A Case Study of Self-Organization in Primary Care

Context: Primary care clinics have experienced unprecedented changes to clinical and administrative routines to keep pace with changing pandemic requirements. Conceptualized as complex, adaptive systems, primary care clinics self-organize to maintain a workable balance. Self-organization varies and is not predictable; each clinic re-organizes routines by adapting its existing configurations of relationships among people, technologies, and material resources. Self-organization has proven hard to study, methodologically.

Objective: Illuminate how a primary care clinic self-organizes over time in the face of multiple pressures, including those related to the COVID-19 pandemic.

Study design/analysis: Virtual case study May – Nov 2021, including virtual meeting observations, document collection, interviews with clinic members, and brief weekly discussions to detect changes in clinical and administrative routines. Using schema analysis, and applying complexity theory and actor-network theory concepts, we described different adaptations chronologically, and then explored inter-relationships. We sought feedback on early results from the participating clinic (member checking).

Setting: Mid-sized urban city in Canada.

Population studied: Primary care clinic.

Intervention/instrument: Semi-structured interview guide; field notes.

Outcome measures: N/A.

Results: The pandemic caused disequilibrium in 2020, where former clinical and administrative routines no longer sufficed. In 2021, the clinic continued to self-organize in the face of changing health policies, unintended consequences of earlier adaptations, and quality improvement initiatives. The clinic developed new feedback methods to detect emerging problems. Physical space, staffing, and technology were obvious influences on self-organization; changing one created ripple effects, sometimes generating new problems. Member checking confirmed we captured most of self-organization occurring during the case study period.

Conclusions: The virtual case study illuminates the complex self-organization occurring in primary care over a year into the pandemic. Rather than expecting a return to ‘normal’, primary care clinics should be approached as changing entities with unique people-technology-resources relationships that are under continual revision. The findings support reflection by clinics on their own processes, as well as for external bodies who support or seek further change within primary care.