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June 2020 (Volume 98)
Quarterly Article
Benjamin F. Crabtree
Jenna Howard
William L. Miller
DeAnn Cromp
Clarissa Hsu
Katie Coleman
Brian T. Austin
Margaret Flinter
Leah Tuzzio
Edward H. Wagner
December 2025
Mental Health and Substance Use Challenges
September 2025
Back to The Milbank Quarterly
Policy Points:
• An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. • The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. • Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes.
Context: Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes.
Methods: A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices.
Findings: We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes—anticipating the future and developing formal processes—that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others.
Conclusions: Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
Keywords: leadership, primary care, complex adaptive system theory, qualitative research.
Read on Wiley Online Library
Published May 2020 DOI: 10.1111/1468-0009.12456