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CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Implementation Research Theoretical Research Theoretical Frameworks Frameworks CyberSeminar Series CyberSeminar Series 4-Part Series: 1.April 7 2.April 14 3.May 5 4.May 12

CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

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Page 1: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler/Damschroder, Theoretical Frameworks

Implementation Implementation Research Theoretical Research Theoretical

FrameworksFrameworksCyberSeminar Series CyberSeminar Series

4-Part Series:1.April 72.April 143.May 54.May 12

Page 2: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

ObjectivesObjectives

Purpose/potential value and uses Process for selection and use Nature and underlying rationale of

specific frameworks/approaches Evaluation

Page 3: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

APRILAPRIL April 7: Foundations

Cheryl Stetler & Laura Damschroder

April 14: Applying a Framework

Phil Ullrich

A Mixed-model Approach-Intro

Jeffrey Smith

Page 4: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

MAYMAY

May 5: A Mixed-model Approach-Cont. Jeffrey Smith

Applying the CFIRLaura Damschroder & Teresa

Damush

May 12: Respond to Participant Interests/

Dialogue with Presenters The “Theory” Team

Page 5: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Your Active Your Active ParticipationParticipation

Track questions & observations General & per framework/approach

DISCUSSION/REACTION FORM page 1 DISCUSSION/REACTION FORM page 2

Send your suggestions for discussion at the May 12th session

Send as early as possible to:[email protected]

Page 6: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

FoundationsFoundations

What are implementation “theories”?

How and why are they useful?

Page 7: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Foundations Foundations TerminologyTerminology

Theory Theoretical/conceptual

framework Model

Page 8: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

HandoutHandout THEORY: “A set of logical constructs that jointly offer

answers to the questions ‘why’ and ‘how,’ as in ‘why would someone change their behavior in this way?’ and ‘how could this behavior/situation/ outcome be changed” (Sales, et al, 2006)

THEORETICAL/CONCEPTUAL FRAMEWORK: “…identifies a set of variables and relationships that should be examined in order to explain the phenomena”; “…need not specify the direction of relationships or identify critical hypotheses” (Kitson et al, 2008)

Page 9: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

TheoryTheory

Provides a denser and logically coherent set of relationships

Sheds light on causal relationships and seeks to explain the phenomena

Offers explanations, predictions and thus “control”

Page 10: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Theoretical or Theoretical or Conceptual Conceptual FrameworkFramework

More specific and concrete than theory Can usually be shown in a

diagram/picture “… could be populated by multiple

theories, at multiple levels” (Kitson et al, 2008)

Page 11: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

ModelModel Represents a specific situation Narrower in scope More precise in their assumptions –

including relationships (Kitson et a, 2008)

May be used interchangeably with “framework” (Sales, et al., 2006)

Page 12: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

No Commonality… No Commonality… IllustrationIllustration11!!

Conceptual models Theories of change Frameworks

1. Ref: Graham & Tetroe, in press

Page 13: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Why “Theory”?Why “Theory”?

Theories, models, frameworks provide a systematic method:

… for identifying, understanding, operationalizing & evaluating the black box phenomenon =

“IMPLEMENTATION”

Page 14: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Why NOT Theory?Why NOT Theory? Just “use common sense”1

Using theory doesn’t make it any easier to judge applicability of evidence

It isn’t clear how to translate theory reliably to study design

So many theories why should any one of them be given supremacy?

BUTBUT: “Common Sense” alone hasn’t worked so far…

Trial & error approach Reinventing the wheel Cherry-picking interventions Retrospectively trying to understand the black box

1. Bhattacharyya O, Reeves S, Garfinkel S, Zwarenstein M. Designing theoretically-informed implementation interventions: fine in theory, but evidence of effectiveness in practice is needed. Implement Sci 2006;1:5.

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CIPRS: Stetler & Damschroder Theoretical Frameworks

Why “Theory”:Why “Theory”:QUERI Dual ObjectivesQUERI Dual Objectives

1. Generalize knowledge about how to implement and sustain interventions

Facilitate systematic accumulation of generalizable knowledge Across studies Across settings Across interventions …other salient characteristics/factors

Page 16: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

QUERI Dual ObjectivesQUERI Dual Objectives

2. Replicate successful implementation

Help navigate complexity of implementation & sustainability

Tailor essential factors to fit the context

Page 17: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Using Theory for Implementation Using Theory for Implementation PlanningPlanning

Select theory of planned behaviorchange

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on theory)

Identify interventiontools that fit bothstrategy and theory

Launch interventionusing identified toolsand strategies

Evaluate effectivenessof intervention,strategies, tools

See references: Sales et al., 2006

Page 18: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Select theory of planned behaviorchange

Using Theory for Implementation Using Theory for Implementation PlanningPlanning

See references: Sales et al., 2006

Assess fit with initial theory

Identify potential strategies for achieving change

Select interventionsthat fit with plannedstrategies (based on theory)

Identify interventiontools that fit bothstrategy and theory

Launch interventionusing identified toolsand strategies

Evaluate effectivenessof intervention,strategies, tools

Select theory of planned behavior

change

Theories

Models

Frameworks

Page 19: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Selecting a Theory - 1Selecting a Theory - 1 Consider Context

Study characteristics Professional discipline/perspective Intervention characteristics Inner and outer setting Individuals involved Implementation process

Consider Level Individuals Teams Organization System

Page 20: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Selecting a Theory - 2Selecting a Theory - 2

Multiple theories often needed Process theories

How implementation should be planned, organized and scheduled

Impact theories Hypotheses and assumptions about how

implementation activities will facilitate a desired change, as well as the facilitators and barriers for success

Adapted from: Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85(1):93-138.

Page 21: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Theories re:Theories re:ImplementationImplementation NOT: Patient care models

Self management; e.g., health belief model NOT: Practice delivery models

Chronic care model IT support: clinical reminders Collaborative care models

Implementation models Individual adoption/uptake Maintenance for sustained use

Page 22: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

TYPES: Process TYPES: Process TheoriesTheories

Aka: Planned Action Theories1

Policy level (example) QUERI core 6-step process

Study level (examples) Graham & Logan’s Ottawa Model of Research Uptake

2

Grol, et al’s model for effective implementation 3

Mendel, et al’s Dissemination Framework 4

Stetler’s Model of Research Utilization/EBP 5

1. See references: Graham & Tetroe, in press2. Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.3. Grol, et al. 20074. Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in organizational and community context: a framework for building evidence on

dissemination and implementation in health services research. Adm. Policy Ment. Health 2008;35(1-2):21-37.5. Stetler C. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nurs Outlook 2001;49/6, 272-278.

Page 23: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Ottawa Model ofOttawa Model ofResearch UseResearch Use

Action-oriented

Prescribes 3 main steps

Assess Monitor Evaluate

Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.

Page 24: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Framework of Dissemination in Health Framework of Dissemination in Health Services Intervention ResearchServices Intervention Research

Mendel et al, 2008

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CIPRS: Stetler & Damschroder Theoretical Frameworks

2001

Page 26: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Impact Theories - 1Impact Theories - 1

Individual-level theories Stage of change Cognitive Educational Motivational

Grol et al, 2007

Page 27: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Individual Level: Stage of Individual Level: Stage of ChangeChange

Stage of change Assumptions about the phases individuals

go through to achieve desired behavior change

General phases common to all1: Awareness Insight Acceptance Actual Change Maintenance

Grol et al, 2007

Page 28: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Literature synthesis of SCT to explain clinician behavior

Godin G, Belanger-Gravel A, Eccles M, Grimshaw J. Healthcare professionals' intentions and behaviours: A systematic review of studies based on social cognitive theories. Implement Sci 2008;3(1):36.

Social Cognitive TheorySocial Cognitive Theory

http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/

Organizational Setting

Page 29: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Theory of Planned Theory of Planned BehaviorBehavior

Motivational theory

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211.http://people.umass.edu/aizen/tpb.diag.htm l

Page 30: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Impact Theories - 2Impact Theories - 2 Social context theories

Social Marketing Social learning Communication Social network & influence Teamwork Professional development Leadership

Grol et al, 2007.

Page 31: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Social Network TheorySocial Network Theory

Tailor engagement strategy to social networks

http://www.istheory.yorku.ca/socialnetworktheory.htm

Page 32: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Impact Theories - 3Impact Theories - 3 Organizational Context Theories

Innovative organizations Quality management Integrated care Complexity Organizational learning Organizational culture

Political & Economic Context Theories Reimbursement Contracting

Grol et al, 2007.

Page 33: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Roger’s Theory of Roger’s Theory of DiffusionDiffusion

Characteristics of the intervention

Organizational characteristics

Environmental context

Adoption decision

Effective implementation

Outcomes

Application to infection prevention practicesKrein SL, Olmsted RN, Hofer TP, Kowalski C, Forman J, Banaszak-Holl J, et al. Translating infection prevention evidence into practice using quantitative and qualitative research. Am. J. Infect. Control 2006;34(8):507-12.

Page 34: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Greenhalgh, et al’s Greenhalgh, et al’s Conceptual ModelConceptual Model

Page 35: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

PARiHS PARiHS FrameworkFramework 3 major domains

Evidence Context Facilitation

Continuums of high and low values that interrelate to influence implementation

Low

Evidence

High

HighContext

Facilitation

High

Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual. Health Care 1998;7(3):149-58.

Positive influence

Negative influence

Page 36: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

PRISM: PRISM: Practical, Robust Practical, Robust Implementation and Sustainability Implementation and Sustainability ModelModel

4 Domains: Intervention

Design Recipients External

Environment Implementation

& Sustainability Infrastructure

See references: Feldstein & Glasgow, 2008

Page 37: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Implementation Implementation Effectiveness ModelEffectiveness Model

Quantitative measures of predictors of implementation effectiveness Strength of relationships empirically

estimated

Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. J Appl Psychol. 2001;86(5):811-824.

Page 38: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

CFIRCFIRConsolidated Framework for Consolidated Framework for

Implementation ResearchImplementation Research

List of 39 constructs that influence implementation

No specific relationships defined

Reflects theory from multiple disciplines and findings from empirical research

Code

ABCDEF

Complexity

GDesign Quality and Packaging

HCost

II. OUTER SETTING

APatient Needs & Resources

BCosmopolitanism

CPeer Pressure

DExternal Policies & Incentives

III. INNER SETTING

A

Structural Characteristics

BNetworks & Communications

CCulture

DImplementation Climate

1Tension for Change

2Compatibility

3Relative Priority

4Organizational Incentives & Rewards

5Goals and Feedback

6Learning Climate

DReadiness for Implementation

123

ABCDE

AB

2

CD

See references: Damschroder et al. Under Review.

Page 39: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Dual QUERI Objectives: Dual QUERI Objectives: RevisitedRevisited

Generalize knowledge about how to implement and sustain interventions

Replicate successful implementation

Page 40: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler/Damschroder, Theoretical Frameworks

Selecting &Selecting & Using a Using a Theoretical Theoretical FrameworkFramework

Page 41: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Uses/Potential Value Uses/Potential Value [PDI*][PDI*]

Provide a way of thinking about a study/project/implementation

Focus the user on what is important to the issue

Understand your EB-innovation/ recommendation/change

Develop a plan for formative evaluation; e.g., diagnostic analysis of barriers to and influences on using targeted best practices and applying an implementation strategy

Select and tailor interventions to promote the use of evidence [Intervention mapping]

Assist with operational definitions of intervention element

Describe relationships among elements/constructs

Guide development of hypotheses to test implementation science

Identify concepts that may be of importance and need to be statistically controlled or tracked

Help with measurement Facilitate interpretation re:

influences and meanings Identify boundaries around the

project/study Provide a framework for

summarizing, reporting findings

Page 42: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Specific Selection and Specific Selection and Use: QUERI CentersUse: QUERI Centers

Use: Facilitate strategic planning overall Guide implementation science goals

Study, understand, predict causal mechanisms/paths

Evaluate chosen framework/s Selection:

Open selection; one or multiple “NO NEW THEORIES” [Banff, International

Conference, 2008]

Page 43: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

““Theoretical” SelectionTheoretical” Selection Origins of the

framework Meaning of the

framework Logical consistency Generalizability Parsimony Testability Usefulness

[Grol et al., 2007]

“QUERI” Evaluation:• In-depth

understanding• Theory criteria• Overall strengths• Overall limitations

• Missing elements

[QUERI PDI Working Group]

Page 44: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Specific Selection and Specific Selection and Use: QUERI ProjectsUse: QUERI Projects

Use: Assessment Intervention planning Hypothesis generation Evaluation

Black box of implementation and progressive/interim outcomes

Usefulness of chosen theories

Selection: Based on the issue at hand Apparent relevance of your “broad” center

framework Strengths, limitations, relevance

Page 45: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Project: Theory Selection and Project: Theory Selection and

UseUse 1. Your targeted EBP recommendation:

a. Explore others’ relevant experiences and results (Grey & published literature):Did they use process/impact theories? Which and to what

effect?Evidence of WHY and HOW a particular intervention/ strategy

did or did not work therein?Did they use isolated, atheoretical interventions or a multi-

faceted strategy?Evidence of WHY and HOW a particular intervention did or did

not work therein?What related barriers, facilitators, determinants have been

identified?Outside of QUERI?Prior Center work, including Step 3 activity?

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CIPRS: Stetler & Damschroder Theoretical Frameworks

Project: Theory Selection and Use Project: Theory Selection and Use cont’dcont’d

b. Understand the nature of your innovation (e.g., per Rogers):

What are its attributes/characteristics? “Core/peripheral” to the clinician’s sense of their practice Complex or “simple” Obvious appeal or the reverse; etc.

What are the potential targets of change? Per Level/s: Individual, team, clinic, organization?

[CAVEAT: “Individuals” work in a context] Per Stage/focus of change: Awareness, knowledge,

skills, self-perception, attitude, behavior, systems, structures, etc.

Given this information, have potentially influential factors been clearly identified?

Page 47: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Project: Theory Selection and Use Project: Theory Selection and Use cont’dcont’d

2. Choose “2” implementation theories to “try” as a “way of thinking” about your particular issue:

Per your general knowledge of their focus and or prior use

Per their strengths, limitations, potential usefulness for your issue

3. Assess “fit” of these various frameworks and make selection/s of one or more, as appropriate

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CIPRS: Stetler & Damschroder Theoretical Frameworks

4.4. Plan your implementation project Plan your implementation project in context of the selected in context of the selected frameworkframework

a. Define relevant terms Conceptually Operationally /measurement and/or actions

b. Develop formative evaluation questions/tools [E.g., if PARIHS-related]

Local diagnostic analysis: E.g., assess likely barriers (How do stakeholders perceive the attributes of the expected change?)

Implementation-focused: E.g., actual barriers (To what extent does leadership actually support the new practice or adoption efforts?)

Progress-focused: E.g., interim staff performance on the new, expected innovation (Relates to designated outcomes or “successful implementation”)

Theoretical/Interpretive: E.g., to what extent did the framework provide an adequate description of results and related influential factors? (Were any significant factors missing?)

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CIPRS: Stetler & Damschroder Theoretical Frameworks

4. Plan… Plan… cont’dcont’d

c. Select interventions, per theory/theories and in light of:

Expected barriers Prior studies’ findings Local diagnostic data

(Simple example: Complex E-B delivery system) Per PARIHS model, consider use of an external facilitator & routine

audit/feedback system; based on identified concerns of clinicians regarding strength of the evidence, additionally use social marketing actions/theory; based on prior similar study findings, use other “facilitation” techniques such as clinical reminder.

d. Identify “theory-related” hypotheses to be tested(Simple example: Complex E-B delivery system)

Test hypothesis that sites with an external facilitator will be more successful than comparison sites under analogous conditions of limited resources and passive leadership.

Page 50: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Application ExamplesApplication Examples

April 14: Applying a Framework

Phil Ullrich A Mixed-model Approach-Intro

Jeffrey Smith

May 5: A Mixed-model Approach-Cont.

Jeffrey Smith Applying the CFIR

Laura Damschroder & Teresa Damush

Page 51: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

Challenges of Challenges of Understanding the Black Understanding the Black BoxBox

Implementation theories under-studied May be “borrowed” Few have been critically analyzed for

strengths/limitations Measurement tools limited Published studies use of theory

often unclear or absent

Page 52: CIPRS: Stetler/Damschroder, Theoretical Frameworks Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: 1. April 7 2. April

CIPRS: Stetler & Damschroder Theoretical Frameworks

QUERI’s Dual FunctionQUERI’s Dual Function

Improve practice through scientifically-based implementation

Increase understanding of implementation science

Transp

arent

Select

ion, U

se,

Evaluatio

n &

Explicit

Reporting o

f

THEORETICAL

FRAMEW

ORKS

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CIPRS: Stetler & Damschroder Theoretical Frameworks

DISCUSSION/REACTION FORM