11/22/2023 0 Comments Complexity theory and activity theory![]() ![]() The Plan-Do-Study-Act (PDSA) cycle of CQI is a sequential, iterative learning model representative of the scientific method with some of the characteristics of the mechanistic conceptual model described above. For this reason, others have emphasized the need to understand the interplay between context, structure, and process as a necessary antecedent to designing and implementing interventions that seek to improve outcomes. 9 The importance of the context within which a practice is situated is evident when efforts to apply an intervention developed in 1 setting yield unexpected results in another. 3 – 6 However, standardizing care without identifying desirable variation or unique adaptations that take advantage of local opportunities and strengths (sometimes referred to as “positive variation” or “positive deviance” 7, 8) misses an important opportunity to identify and investigate unanticipated circumstances or locally adapted practice configurations associated with better health care outcomes. Its application in health care has also tended to be mechanistic, with undesirable variation in health service delivery (e.g., units achieving outcomes below the group mean) often regarded as an alteration in normal functioning. First, the conceptual framework for quality improvement, rooted in an industrial (manufacturing) model, uses a mechanical view of the systems that humans create and focuses on incremental change to reduce variation. This approach has important conceptual and analytical limitations, however. Past initiatives to enhance care in VHA and elsewhere have been based, to a significant extent, on the continuous quality improvement (CQI) model. ![]() 1 An analysis of care within VHA, however, demonstrates significant and sometimes undesirable variation at the facility level in many of the processes and intermediate outcomes of both chronic disease management and prevention. Each veteran is assigned a primary care provider who is responsible for coordinating access to services, meeting specific health care needs, and providing services that promote wellness and reduce risk for preventable illness. The Veterans Health Administration (VHA), the largest integrated health care system in the United States, provides care to more than 6 million veterans. ![]()
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