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The Consolidated Framework for Implementation Research (CFIR)

A Roadmap to Implementation

By Alexie Touchette

In this post, we summarize a 2009 article by Damschroder et al. published in Implementation Science, discussing development of the Consolidated Framework for Implementation Research (CFIR) — a framework to guide the application of research findings to real world settings.

View the full publication at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736161/

Why a Consolidated Framework?

As we’ve discussed previously, there are a plethora of theories, models and frameworks in the knowledge translation (KT) and implementation literature, many of which are rarely used, most of which use different terminologies and definitions. The problem is that none of these theories, models, or frameworks are fully comprehensive.

The Consolidated Framework for Implementation Research, or CFIR, aims to provide a comprehensive framework for implementation of research findings into practice [1]. It draws upon 19 theories, models, and frameworks, using snowball sampling to identify studies, until no new concepts were found.

CFIR vs. TDF

Similar to the Theoretical Domains Framework (TDF), the aim of the CFIR is to provide a pragmatic organization of constructs (i.e. factors) that appear to influence the process of implementation within general domains. Both are determinant frameworks that help identify and explain factors that influence implementation — they are both ‘lists’ in this sense, and can both be used for implementation planning and evaluation. The key difference is that while the TDF focuses primarily on factors influencing individual healthcare provider behaviour (i.e. at the individual level), the CFIR domains also consider factors at organizational and broader societal levels — hence why there are many more constructs in the CFIR. Although it is not uncommon for these to be used together [2], they are not interchangeable, and researchers should ensure that their use in implementation is clearly defined and reported.

An Overview of the CFIR

The CFIR is organized into five domains based on context (intervention, outer setting, inner setting, individual and process). Each is described below. Overall, the CFIR is intended to help identify potential factors (i.e. barriers and facilitators) that are believed to influence implementation. However, it doesn’t specify the existence or direction of interactions between these factors.

The authors emphasize that the CFIR does not apply to every implementation problem. Instead, the factors (constructs) deemed relevant to a situation or intervention need to be identified (often via questionnaires, observation, and/or interviews), and strategies devised to address each construct. The impact of these strategies on the targeted domains need to be monitored regularly to determine progress and effectiveness, as well as to monitor the potential impact of unanticipated factors affecting implementation.

Although the CFIR is depicted in a very linear manner, the five domains and their respective constructs can’t be considered in isolation, as they interact to influence implementation.

Continue reading below for a description of each domain and its constructs.

Domain 1: Intervention Characteristics

In this domain, what matters are the features and quality of the intervention, and how the intervention is perceived by those responsible for behavioural changes that are part of the intervention — such as nurses, clinicians, and even patients. Constructs in the CFIR related to intervention characteristics include:

Intervention source

Do stakeholders perceive the intervention as being developed internally or externally? This may influence implementation success. As an example, the authors indicate that “if the decision to adopt and implement is made by leaders higher in the hierarchy who edict change with little user input in the decision to implement an intervention, implementation is less likely to be effective.”

Evidence strength and quality

How do stakeholders perceive the evidence supporting this intervention and its supposed outcomes? The perceived credibility and strength of evidence may affect implementation success. Evidence may come from external (e.g. published literature or guidelines) or internal sources (e.g. best practices, patient experience).

Relative advantage

Do stakeholders believe this intervention will work better than other alternatives? Benefits must be clearly observable for stakeholders to be able to assess the advantages of choosing one intervention over another, which may be difficult for certain interventions.

Adaptability

Can the intervention be adapted for local contexts/needs? Interventions may include “core components” (essential, non-alterable elements), and the “adaptable periphery” (elements that can be changed). The example provided: “a computerized report system has a fundamental core that users cannot change but it might be accessed from different launch points, depending on workflows of individual organizations.”

Trialability

Can the intervention be tested on a smaller scale within the organization, and can it be reversed if needed? “The ability to pilot an intervention has a strong positive association with effective implementation” by building experience and allowing time for reflection.

Complexity

How difficult do stakeholders perceive the intervention to be? This is reflected in its duration, scope, radicalness, disruptiveness, centrality, intricacy and number of steps required to implement — all of which have a negative association with implementation success.

Design Quality and Packaging

How is the intervention presented? “When intervention quality is perceived to be poor by users, there are negative consequences for employee satisfaction and intervention use.”

Cost

How much does the intervention cost — including investment, supply, and opportunity costs (the cost of choosing one intervention over alternatives)? All are negatively associated with implementation success.

Domain 2: Outer Setting

Outer setting refers to the economic, political, and social contexts where the organization resides. This includes the various levels of government overseeing a healthcare system, businesses involved in (or affected by) the healthcare system, and society in general.

Patient Needs and Resources

Are patients’ needs known and prioritized by the organization (as well as barriers or facilitators that affect meeting those needs)? Evidence from the field of quality improvement indicates an emphasis on the client (i.e. patient) is an essential “core component” for successful implementation.

Cosmopolitanism

A fancy way of saying: is the organization networked with other external organizations?

Peer Pressure

Is there pressure from competing organizations to implement an intervention/change?

External Policies and Incentives

Are there any policy, recommendations, or mandates to implement the intervention?

Domain 3: Inner Setting

Inner setting refers to the structural, political, and cultural contexts where the implementation will take place — such as an organization (or department, building, group of people, etc.).

Structural Characteristics

How old is the organization? How big is the organization? How are people clustered and organized into smaller groups? These characteristics are usually quantitative in nature, and all influence implementation. For example, “The more stable teams are (i.e. members are able to remain with the team for an adequate period of time; low turnover), the more likely implementation will be successful” [3]. Additionally, a higher ratio of managers to total employees is positively associated with innovation [4].

Network and Communications

How are social networks organized? Is there good communication between individuals, units, services, and organization levels? A higher quality of formal communications is a contributor to effective implementation [5].

Culture

What are the cultural norms, values, and basic assumptions? The intervention should be targeted at both visible aspects of an organization and less tangible (perhaps even subconscious) organizational assumptions and thinking.

Implementation Climate

How receptive are individuals to the intervention? Will the use of the intervention be rewarded and supported by leaders? Six sub-constructs influence implementation climate:

  • Need for Change: Do stakeholders perceive the current situation as needing change?
  • Compatibility: How well does the intervention fit with the organizational culture? Do stakeholders perceive a ‘match’ between the meaning they attach to an intervention, and the meaning attached to it by upper management?
  • Relative Priority: In the grand scheme of things, how important is the intervention when compared to competing priorities of individual stakeholders, upper management, and the organization as a whole?
  • Organizational Incentives and Rewards: Are there tangible incentives to adopt the intervention, such as promotions, raises, improved autonomy, or other forms of recognition?
  • Goals and Feedback: Are organizational goals clearly communicated to staff, and are they given feedback about progress and performance? Multiple methods of evaluation and feedback are important to an effective intervention.
  • Learning Climate: Do leaders openly share their own mistakes and needs? Do team members feel that they are essential and valued in the change process? Do individuals feel safe to try new methods? Is there enough time and space for reflective thinking and evaluation? These all contribute to a positive learning climate.
  • Readiness for Implementation: Are leaders and managers committed and involved in the implementation? Have the necessary resources (money, time, personnel) been defined, and are they available? Information about how to implement the intervention should be readily available and easily understood to everyone involved.

Note that the line between inner and outer setting isn’t always clear, and that the specific factors considered to be either inner or outer setting depends on the contexts of the implementations.

Domain 4: Individuals

Change doesn’t start at the organization level — it begins with changes by individuals (who can then influence other individuals), and is dependent on their mindset, norms, interest, and affiliations.

Knowledge and Beliefs about the Intervention

What are peoples’ attitudes, values, and familiarity with facts associated with the intervention? An intervention perceived as valuable and positive is (obviously) associated with greater intention to change — a precursor to making that change (from the Theory of Planned Behaviour) [6].

Self-Efficacy

How much do individuals believe in their own capabilities to execute the intervention? The more confident an individual feels doing a certain task within a certain context, the higher their self-efficacy. In turn, a higher self-efficacy positively affects the likelihood that the individual will embrace and commit to the intervention.

Individual Stage of Change

Are individuals progressing toward skilled, enthusiastic, and sustained use of the intervention? The different stages of change will depend on the model used in the intervention (e.g. Prochaska & Di Clemente’s Transtheoretical Model of Behavior Change, Rogers’ Diffusion of Innovations Theory, Grol & Wensing’s Model for Effective Implementation [7]).

Individual Identification with the Organization

How does the individual perceive the organization? What is their relationship to the organization, and how committed are they?

Other Personal Attributes

Other personal traits may have varying levels of impact on implementation success (i.e., skills and knowledge, optimism, motivation, etc.).

Domain 5: Implementation Process

The process of change is usually not linear, nor sequential. It often involves a series of smaller processes occurring at the same time, but at different levels within the organization.

Planning

Have the proper steps to promote effective implementation been established and put in place? These steps and the content of the plan will depend on the theory, model, or framework used to guide change at the individual and organizational level. Considerations include when the implementation details were developed, whether the process was formal or informal, and if they consider both modifiable and non-modifiable factors.

Planning also includes consideration of stakeholder needs and perspectives, tailoring of strategies for certain subgroups of people, the method of education of the intervention (style, imagery, use of metaphors), the use of appropriate communication channels, progress tracking, and strategies for simplifying execution.

Engaging

Who is involved in the implementation? Does the implementation effort have a champion, and how were they brought in? What is their role in the organization and in the implementation? Individuals within the organization will be more likely to engage in the intervention if those leading the change have similar socioeconomic, professional, educational, and cultural backgrounds to them.

The authors identify four different types of individuals in the context of change:

  • Opinion Leaders: Expert or peer opinion leaders who exert their influence on others.
  • Formally-Appointed Internal Implementation Leaders: Individuals who work for the organization who are responsible for implementing the intervention as coordinators, project managers, team leaders, etc.
  • Champions: People who actively and enthusiastically promote the implementation.
  • External Change Agents: Individuals external to the implementation process who facilitate intervention decisions (such as a knowledge broker).

Though it may seem daunting, the CFIR is intended to be comprehensive, and allows for a structured and pragmatic approach to identifying “complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories.” It provides the foundation for an understanding of the multitude of factors influencing implementation, and is a valuable tool for KT researchers.

About the Author

Alexie Touchette is a Research Coordinator with the Department of Community Health Sciences at the University of Manitoba.

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