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Updated: Dec 7, 2025

An R-Based Landscape Validation of a Competing Risk Model
Published on: September 16, 2022
Rugged landscapes: complexity and implementation science
Joseph T Ornstein1,2, Ross A Hammond3,4, Margaret Padek3,5,6
1Brown School, Washington University in St. Louis, Brookings Drive, St. Louis, MO, USA. jornstein@wustl.edu.
Background:
Mis-implementation-defined as failure to successfully implement and continue evidence-based programs-is widespread in public health practice. Yet the causes of this phenomenon are poorly understood.
Methods:
We develop an agent-based computational model to explore how complexity hinders effective implementation. The model is adapted from the evolutionary biology literature and incorporates three distinct complexities faced in public health practice: dimensionality, ruggedness, and context-specificity. Agents in the model attempt to solve problems using one of three approaches-Plan-Do-Study-Act (PDSA), evidence-based interventions (EBIs), and evidence-based decision-making (EBDM).
Results:
The model demonstrates that the most effective approach to implementation and quality improvement depends on the underlying nature of the problem. Rugged problems are best approached with a combination of PDSA and EBI. Context-specific problems are best approached with EBDM.
Conclusions:
The model's results emphasize the importance of adapting one's approach to the characteristics of the problem at hand. Evidence-based decision-making (EBDM), which combines evidence from multiple independent sources with on-the-ground local knowledge, is a particularly potent strategy for implementation and quality improvement.
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