Using codesign to engage primary care practices in a participatory change process

Healthcare has experienced significant transformation in recent years with many changes being imposed on practices from outside sources. When tailoring outside interventions to specific settings, it is important to engage practice members in participatory processes. Yet, tailoring remains a difficult and poorly understood element of implementation. Codesign is one method to achieve context-sensitive, bottom-up change by engaging stakeholders in the design process. With a complex adaptive system (CAS) perspective, codesign reframes interventions as tools to empower practices to drive change based on local challenges and experiences rather than change being imposed upon them. Observing adaptations and facilitating innovations of practice members offers insight into dynamics of the CAS, implementation context, and its limitations. Here, the codesign process is illustrated through a pediatric primary care practice adopting integrated health. Contextual inquiry was performed using ethnographic observations to identify barriers and facilitators to integrated health. Observation findings informed codesign workshops with clinicians. Workshop transcripts and drawings were analyzed using an immersion/crystallization approach guided by the Practice Change Model (PCM), an established framework based on complexity science concepts. In these workshops, clinicians described tension between their motivations to care for complex patients and limitations imposed by the health system. Participants' knowledge of their real-world context allowed them to identify resources and opportunities for changes they could make within their current environment. The reconciliation of the ideal and the real is a core benefit of codesign methods. This innovative approach can be applied more generally to support the development, implementation, and evaluation of interventions that reflect real world interactions and complexities.