Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

Intervention source

Perception of key stakeholders about whether the intervention is externally or internally developed [8]. An intervention may be internally developed as a good idea, solution to a problem, or other grass-roots effort, or may be developed by an external entity (e.g., vendor or research group) [8]. The legitimacy of the source may also influence implementation.

Evidence strength and quality

Stakeholders' perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes. Sources of evidence may include published literature, guidelines, anecdotal stories from colleagues, information from a competitor, patient experiences, results from a local pilot, and other sources [9, 27].

Relative advantage

Stakeholders' perception of the advantage of implementing the intervention versus an alternative solution [28].

Adaptability

The degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs. Adaptability relies on a definition of the 'core components' (the essential and indispensible elements of the intervention itself) versus the 'adaptable periphery' (adaptable elements, structures, and systems related to the intervention and organization into which it is being implemented) of the intervention [8, 10], as described in the Overview section. A component analysis can be performed to identify the core versus adaptable periphery components [29], but often the distinction is one that can only be discerned through trial and error over time as the intervention is disseminated more widely and adapted for a variety of contexts [26]. The tension between the need to achieve full and consistent implementation across multiple contexts while providing the flexibility for local sites to adapt the intervention as needed is real and must be balanced, which is no small challenge [30].

Trialability

The ability to test the intervention on a small scale in the organization [8], and to be able to reverse course (undo implementation) if warranted [31]. The ability to trial is a key feature of the plan-do-study-act quality improvement cycle that allows users to find ways to increase coordination to manage interdependence [32]. Piloting allows individuals and groups to build experience and expertise, and time to reflect upon and test the intervention [33], and usability testing (with staff and patients) promotes successful adaptation of the intervention [31].

Complexity

Perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement [8, 23]. Radical interventions require significant reorientation and non-routine processes to produce fundamental changes in the organization's activities and reflects a clear departure from existing practices [8]. One way to determine complexity is by assessing 'length' (the number of sequential sub-processes or steps for using or implementing an intervention) and 'breadth' (number of choices presented at decision points) [34]. Complexity is also increased with higher numbers of potential target organizational units (teams, clinics, departments) or types of people (providers, patients, managers) targeted by the intervention [34], and the degree to which the intervention will alter central work processes [23].

Design quality and packaging

Perceived excellence in how the intervention is bundled, presented, and assembled [35].

Cost

Costs of the intervention and costs associated with implementing that intervention, including investment, supply, and opportunity costs. It is important to differentiate this construct from available resources (part of inner setting, below). In many contexts, costs are difficult to capture and available resources may have a more direct influence on implementation.

Patient needs and resources

The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization. Clearly, improving the health and well-being of patients is the mission of all healthcare entities, and many calls have gone out for organizations to be more patient centered [21]. Patient-centered organizations are more likely to implement change effectively [36]. Many theories of research uptake or implementation acknowledge the importance of accounting for patient characteristics [31, 33, 37], and consideration of patients needs and resources must be integral to any implementation that seeks to improve patient outcomes [21]. The Practical, Robust Implementation and Sustainability Model PRISM delineates six elements that can help guide evaluation of the extent to which patients are at the center of organizational processes and decisions: patient choices are provided, patient barriers are addressed, transition between program elements is seamless, complexity and costs are minimized, and patients have high satisfaction with service and degree of access and receive feedback [31].

Cosmopolitanism

The degree to which an organization is networked with other external organizations. Organizations that support and promote external boundary-spanning roles of their staff are more likely to implement new practices quickly [8]. The collective networks of relationships of individuals in an organization represent the social capital of the organization [38]. Social capital is one term used to describe the quality and the extent of those relationships and includes dimensions of shared vision and information sharing. One component of social capital is external bridging between people or groups outside the organization [8].

Peer pressure

Mimetic or competitive pressure to implement an intervention, typically because most or other key peer or competing organizations have already implemented or in pursuit of a competitive edge. 'Peers' can refer to any outside entity with which the organization feels some degree of affinity or competition at some level within their organization (e.g., competitors in the market, other hospitals in a network). The pressure to implement can be particularly strong for late-adopting organizations [39].

External policies and incentives

Broad constructs that encompass external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting [26].

Structural characteristics

The social architecture, age, maturity, and size of an organization. Social architecture describes how large numbers of people are clustered into smaller groups and differentiated, and how the independent actions of these differentiated groups are coordinated to produce a holistic product or service [40]. Structural characteristics are, by-and-large, quantitative measures and, in most cases, measurement instruments and approaches have been developed for them. Damenpour conducted a meta-analysis of many structural determinants based on 23 studies conducted outside the healthcare sector [41]. Functional differentiation is the internal division of labor where coalitions of professionals are formed into differentiated units. The number of units or departments represents diversity of knowledge in an organization. The more stable teams are (members are able to remain with the team for an adequate period of time; low turnover), the more likely implementation will be successful [42]. Administrative intensity (the ratio of managers to total employees) is positively associated with innovation [41]. Centralization (the concentration of decision-making autonomy) has been shown to be negatively associated with innovation [41], but has also been found to be positive or negatively associated, depending on the stage of intervention (initiative stage versus implementation stage) [43]. Size, age, maturity, and degree of specialization (the uniqueness of the niche or market for the organization's products or services) also influence implementation [8].

Networks and communications

The nature and quality of webs of social networks and the nature and quality of formal and informal communications within an organization. Research on organizational change has moved beyond reductionist measures of organizational structure, and increasingly embraces the complex role that networks and communications have on implementation of change interventions [44]. Connections between individuals, units, services, and hierarchies may be strong or weak, formal or informal, tangible or intangible. Social capital describes the quality and the extent of relationships and includes dimensions of shared vision and information sharing. One component of social capital is the internal bonding of individuals within the same organization [8]. Complexity theory posits that relationships between individuals may be more important than individual attributes [45], and building these relationships can positively influence implementation [46]. These relationships may manifest to build a sense of 'teamness' or 'community' that may contribute to implementation effectiveness [42].

Regardless of how an organization is structurally organized, the importance of communication across the organization is clear. Communication failures are involved with the majority of sentinel events in US hospitals [47]. High quality of formal communications contributes to effective implementation [48]. Making staff feel welcome (good assimilation), peer collaboration and open feedback and review among peers and across hierarchical levels, clear communication of mission and goals, and cohesion between staff and informal communication quality, all contribute to effective implementation [48].

Culture

Norms, values, and basic assumptions of a given organization [49]. Most change efforts are targeted at visible, mostly objective, aspects of an organization that include work tasks, structures, and behaviors. One explanation for why so many of these initiatives fail centers on the failure to change less tangible organizational assumptions, thinking, or culture [50].

Some researchers have a relatively narrow definition of culture, while other researchers incorporate nearly every construct related to inner setting. In the next section we highlight the concept of 'climate.' As with 'culture,' climate suffers from inconsistent definition. Culture and climate can, at times, be interchangeable across studies, depending on the definition used [51]. A recent review found 54 different definitions for organizational climate [49] and, likewise, many definitions exist for culture [51]. Culture is often viewed as relatively stable, socially constructed, and subconscious [51]. The CFIR embraces this latter view and differentiates climate as the localized and more tangible manifestation of the largely intangible, overarching culture [49]. Climate is a phenomenon that can vary across teams or units, and is typically less stable over time compared to culture.

Implementation climate

Knowledge and beliefs about the intervention

Individuals' attitudes toward and value placed on the intervention, as well as familiarity with facts, truths, and principles related to the intervention. Skill in using the intervention is a primarily cognitive function that relies on adequate how-to knowledge and knowledge of underlying principles or rationale for adopting the intervention [59]. Enthusiastic use of an intervention can be reflected by a positive affective response to the intervention. Often, subjective opinions obtained from peers based on personal experiences are more accessible and convincing, and these opinions help to generate enthusiasm [59]. Of course, the converse is true as well, often creating a negative source of active or passive resistance [60]. The degree to which new behaviors are positively or negatively valued heightens intention to change, which is a precursor to actual change [61].

Self-efficacy

Individual belief in their own capabilities to execute courses of action to achieve implementation goals [62]. Self-efficacy is a significant component in most individual behavior change theories [63]. Self-efficacy is dependent on the ability to perform specific actions within a specific context. The more confident an individual feels about his or her ability to make the changes needed to achieve implementation goals, the higher their self-efficacy. Individuals with high self-efficacy are more likely to make a decision to embrace the intervention and exhibit committed use even in the face of obstacles.

Individual stage of change

Characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention [23, 35]. The specific stages used will depend on the underlying model being used in the study. Prochaska's trans-theoretical model characterizes these stages as pre-contemplation, contemplation, preparation, and action and maintenance [64]. Rogers' diffusion theory delineates five stages [59]. Grol et al. describe a five-stage model with ten sub-stages based on their synthesis of the literature [23].

Individual identification with organization

A broad construct related to how individuals perceive the organization and their relationship and degree of commitment to that organization. These attributes may affect the willingness of staff to fully engage in implementation efforts or use the intervention [65, 66]. These measures have been studied very little in healthcare, but may be especially important when evaluating the influence of implementation leaders' (described under Process below) on implementation efforts. Organizational citizenship behavior characterizes how well organizational identity is taken on by individuals and whether, because they associate themselves with the organization, they are willing to put in extra effort, talk well of the organization, and take risks in their organization [67, 68]. Organizational justice is an individual's perception of distributive and procedural fairness in the organization [65]. Emotional exhaustion is an ongoing state of emotional and physical depletion or burnout [69], and may negatively influence implementation by stunting the ability and energy of an individual to help or initiate change [70]. The Agency for Healthcare Research and Quality recently published a guide for determining whether a particular implementation will be successful that includes questions about individual perceptions of whether they believe the organization could be doing a better job, belief about whether work is done efficiently, and whether there are inequities as potential barriers to implementation [71]. The organizational social context measure, developed by Glisson et al., includes constructs related to psychological climate (perception of the psychological influence of work environment) and work attitudes (job satisfaction and organizational commitment) [72].

Other personal attributes

This is a broad construct to include other personal traits. Traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, innovativeness [25], tenure [25], and learning style have not received adequate attention by implementation researchers [8].

Planning

The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods. The fundamental objective of planning is to design a course of action to promote effective implementation by building local capacity for using the intervention, collectively and individually [26]. The specific steps in plans will be based on the underlying theories or models used to promote change at organization and individual levels [23]. For example, the Institute for Healthcare Improvement [74, 75], Grol et al. [76], and Glisson and Schoenwald [77] all describe comprehensive approaches to implementation on which implementation plans can be developed. However, these theories prescribe different sets of activities because they were developed in different contexts–though commonalities exist as well. Grol et al. list 14 different bodies of theories for changing behaviors in social or organizational contexts [23], and Estabrooks et al. list 18 different models of organizational innovation [78]. Thus, the particular content of plans will vary depending on the theory or model being used to guide implementation. Implementation plans can be evaluated by the degree to which five considerations guide planning: stakeholders' needs and perspectives are considered; strategies are tailored for appropriate subgroups (e.g., delineated by professional, demographic, cultural, organizational attributes); appropriate style, imagery, and metaphors are identified and used for delivering information and education; appropriate communication channels are identified and used; progress toward goals and milestones is tracked using rigorous monitoring and evaluation methods [8, 59]; and strategies are used to simplify execution. The latter step may include plans for dry runs (simulations or practice sessions) to allow team members to learn how to use the intervention before going live [42], running trials to allow users to test procedures, gain confidence, and build an environment of psychological safety [42], or taking an incremental approach that breaks the intervention down into manageable parts that can be implemented incrementally [41]. The plan can be formal or informal but should consider all salient contextual factors–both modifiable and non-modifiable. Workarounds can be developed for non-modifiable factors, and strategies can be designed to change factors that can be modified (e.g., increase stakeholders' knowledge of the intervention).

Engaging

Executing

Carrying out or accomplishing the implementation according to plan. Execution of an implementation plan may be organic with no obvious or formal planning, which makes execution difficult to assess. Quality of execution may consist of the degree of fidelity of implementation to planned courses of action [29], intensity (quality and depth) of implementation [84], timeliness of task completion, and degree of engagement of key involved individuals (e.g., implementation leaders) in the implementation process.

Reflecting and evaluating

Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience. It is important to differentiate this processual construct from the Goals and Feedback construct under Inner Setting, described above. The focus here is specifically related to implementation efforts. Evaluation includes traditional forms of feedback, such as reports, graphs, and qualitative feedback and anecdotal stories of success [63]. Objectives should be specific, measurable, attainable, relevant, and timely (the SMART rubric) [71]. Less attention is paid in the literature to the need for, and value of, group and personal reflection. Dedicating time for reflecting or debriefing before, during, and after implementation is one way to promote shared learning and improvements along the way [42].