improvements in the quality of this training has generally received little attention.

Batalden offered the following formula as a way of thinking about how the various factors of quality improvement fit together:

In short, by taking general scientific understandings and applying them to a particular context, one should be able to achieve a measurable improvement in performance. There are five distinct knowledge systems underlying this formula, Batalden explained. The first relates to generalizable scientific evidence, which Batalden described as understanding how to minimize the effect of context. The second system of knowledge focuses on understanding the specific variables that define a particular context. The third involves measuring the stability of change over time; this system of knowledge underlies measured performance improvement, which is the outcome—that is, the right-hand side—of the above formula. While Batalden stresses the importance of measurements over time, such measures often do not exist; instead, it is often the case that only discrete pre-and post-intervention measurements are taken. The fourth system of knowledge is implied in the plus sign in the formula: It is the knowledge involved in choosing the correct evidence to a particular context. The fifth system of knowledge, which Batalden calls the knowledge of execution, is the formula’s arrow.

Generalizable scientific evidence and particular contexts link together, creating a cycle that is a form of experiential learning. The cycle begins with testing the implications of concepts in new situations, Batalden explained. These tests lead to concrete experiences, and observations and reffections made from these experiences are then analyzed to form new abstract concepts and generalizations, which can then be tested in new situations, beginning another cycle. Without further testing and analysis, however, this is just experience. This cycle not only describes how a large majority of evidence-based medicine is developed, but it also captures how evidence-based medicine is largely integrated into practice. In fact, Batalden said, the quality improvement field has been substantially handicapped by the idea that only one method to control quality can be used at a time to affect change. While a lot can be learned from studying the effects of individual quality improvements, much can also be learned experientially from a multitude of efforts to improve health

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