Use of theory to interpret elements of change.

Actions useful in reducing unacceptable variation in physicians' clinical activities have been identified through critical reviews of randomized controlled trials, and, from them, Richard Grol proposed six elements of effective change for mounting programs to improve clinical practice. The elements include consideration of the complex reality of clinical practice, attention to the designated change, analysis of the target group and setting, mixed interventions to address needs, and a plan of action. Although empirically based, the elements lack a theoretical underpinning that explains why the elements work. This article interprets the elements using theories separately advanced by Dewey, Slotnick, and Wenger to suggest ways for understanding what studies have shown.