Cultural-historical activity theory is a new framework aimed at transcending the dichotomies of micro- and macro-, mental and material, observation and intervention in analysis and redesign of work. The approach distinguishes between short-lived goal-directed actions and durable, object-oriented activity systems. A historically evolving collective activity system, seen in its network relations to other activity systems, is taken as the prime unit of analysis against which scripted strings of goal-directed actions and automatic operations are interpreted. Activity systems are driven by communal motives that are often difficult to articulate for individual participants. Activity systems are in constant movement and internally contradictory. Their systemic contradictions, manifested in disturbances and mundane innovations, offer possibilities for expansive developmental transformations. Such transformations proceed through stepwise cycles of expansive learning which begin with actions of questioning the existing standard practice, then proceed to actions of analyzing its contradictions and modelling a vision for its zone of proximal development, then to actions of examining and implementing the new model in practice. New forms of work organization increasingly require negotiated 'knotworking' across boundaries. Correspondingly, expansive learning increasingly involves horizontal widening of collective expertise by means of debating, negotiating and hybridizing different perspectives and conceptualizations. Findings from a longitudinal intervention study of children's medical care illuminate the theoretical arguments.