Implementation Research TheoreticalFamework.ppt

Theoretical Framework for research work

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

2. CIPRS: Stetler & Damschroder Theoretical Frameworks
Objectives
Purpose/potential value and uses
Process for selection and use
Nature and underlying rationale of
specific frameworks/approaches
Evaluation

3. CIPRS: Stetler & Damschroder Theoretical Frameworks
APRIL
April 7: Foundations
Cheryl Stetler & Laura Damschroder
April 14: Applying a Framework
Phil Ullrich
A Mixed-model Approach-Intro
Jeffrey Smith

4. CIPRS: Stetler & Damschroder Theoretical Frameworks
MAY
May 5: A Mixed-model Approach-Cont.
Jeffrey Smith
Applying the CFIR
Laura Damschroder & Teresa Damush
May 12: Respond to Participant Interests/
Dialogue with Presenters
The “Theory” Team

5. CIPRS: Stetler & Damschroder Theoretical Frameworks
Your Active Participation
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 12
th
session
Send as early as possible to:
[email protected]

6. CIPRS: Stetler & Damschroder Theoretical Frameworks
Foundations
What are implementation
“theories”?
How and why are they useful?

7. CIPRS: Stetler & Damschroder Theoretical Frameworks
Foundations Terminology
Theory
Theoretical/conceptual framework
Model

8. CIPRS: Stetler & Damschroder Theoretical Frameworks
Handout
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)

9. CIPRS: Stetler & Damschroder Theoretical Frameworks
Theory
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”

10. CIPRS: Stetler & Damschroder Theoretical Frameworks
Theoretical or
Conceptual Framework
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)

11. CIPRS: Stetler & Damschroder Theoretical Frameworks
Model
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)

12. CIPRS: Stetler & Damschroder Theoretical Frameworks
No Commonality…
Illustration
1
!
Conceptual models
Theories of change
Frameworks
1.Ref: Graham& Tetroe, in press

13. CIPRS: Stetler & Damschroder Theoretical Frameworks
Why “Theory”?
Theories, models, frameworks
provide a systematicmethod:
… for identifying, understanding,
operationalizing & evaluating the black
boxphenomenon =
“IMPLEMENTATION ”

14. CIPRS: Stetler & Damschroder Theoretical Frameworks
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?
BUT: “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 Sci2006;1:5.

15. CIPRS: Stetler & Damschroder Theoretical Frameworks
Why “Theory”:
QUERI 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

16. CIPRS: Stetler & Damschroder Theoretical Frameworks
QUERI Dual Objectives
2.Replicate successful
implementation
Help navigate complexity of
implementation & sustainability
Tailor essential factors to fit the
context

17. CIPRS: Stetler & Damschroder Theoretical Frameworks
Using Theory for Implementation
Planning
Select theoryof
planned behavior
change
Assess fit with
initial theory
Identify potential
strategiesfor
achieving change
Select interventions
that fit with planned
strategies
(based on theory)
Identify intervention
tools that fit both
strategy and theory
Launch intervention
using identified tools
and strategies
Evaluate effectiveness
of intervention,
strategies, tools
See references: Sales et al., 2006

18. CIPRS: Stetler & Damschroder Theoretical Frameworks
Select theoryof
planned behavior
change
Using Theory for Implementation
Planning
See references: Sales et al., 2006
Assess fit with
initial theory
Identify potential
strategiesfor
achieving change
Select interventions
that fit with planned
strategies
(based on theory)
Identify intervention
tools that fit both
strategy and theory
Launch intervention
using identified tools
and strategies
Evaluate effectiveness
of intervention,
strategies, tools
Select theory of
planned behavior
change
Theories
Models
Frameworks

19. CIPRS: Stetler & Damschroder Theoretical Frameworks
Selecting 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

20. CIPRS: Stetler & Damschroder Theoretical Frameworks
Selecting a Theory -2
Multiple theories often needed
Processtheories
How implementation should be planned,
organized and scheduled
Impacttheories
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.

21. CIPRS: Stetler & Damschroder Theoretical Frameworks
Theories re:
Implementation
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

22. CIPRS: Stetler & Damschroder Theoretical Frameworks
TYPES: Process Theories
Aka: Planned Action Theories
1
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 press
2. 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. 2007
4. Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in organizational and community context: a frameworkfor building evidence on dissemination and
implementation in health services research. Adm. Policy Ment. Health2008;35(1-2):21-37.
5. Stetler C. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nurs Outlook2001;49/6, 272-278.

23. CIPRS: Stetler & Damschroder Theoretical Frameworks
Ottawa Model of
Research 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.

24. CIPRS: Stetler & Damschroder Theoretical Frameworks
Framework of Dissemination in Health Services
Intervention Research
Mendel et al, 2008

25. CIPRS: Stetler & Damschroder Theoretical Frameworks
2001

26. CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact Theories -1
Individual-level theories
Stage of change
Cognitive
Educational
Motivational
Grol et al, 2007

27. CIPRS: Stetler & Damschroder Theoretical Frameworks
Individual Level: Stage of Change
Stage of change
Assumptions about the phases individuals go
through to achieve desired behavior change
General phases common to all
1
:
Awareness 
Insight 
Acceptance 
Actual Change 
Maintenance
Grol et al, 2007

28. 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 Theory
http://www.cw.utwente.nl/theorieenoverzicht/Theory%2
0clusters/Health%20Communication/Social_cognitive_the
ory.doc/
Organizational
Setting

29. CIPRS: Stetler & Damschroder Theoretical Frameworks
Theory of Planned Behavior
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.html

30. CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact Theories -2
Social context theories
Social Marketing
Social learning
Communication
Social network & influence
Teamwork
Professional development
Leadership
Grol et al, 2007.

31. CIPRS: Stetler & Damschroder Theoretical Frameworks
Social Network Theory
Tailor engagement strategy to social
networks
http://www.istheory.yorku.ca/socialnetworktheory.htm

32. CIPRS: Stetler & Damschroder Theoretical Frameworks
Impact 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.

33. CIPRS: Stetler & Damschroder Theoretical Frameworks
Roger’s Theory of Diffusion
Characteristics of
the intervention
Organizational
characteristics
Environmental
context
Adoption
decision
Effective
implementation
Outcomes
Application to infection prevention practices
Krein 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. Control2006;34(8):507-12.

34. CIPRS: Stetler & Damschroder Theoretical Frameworks
Greenhalgh, et al’s
Conceptual Model

35. CIPRS: Stetler & Damschroder Theoretical Frameworks
PARiHS Framework
3 major domains
Evidence
Context
Facilitation
Continuums of high
and low values that
interrelate to
influence
implementation
Low
Evidence
High
HighContext
High
Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based
practice: a conceptual framework. Qual. Health Care1998;7(3):149-58.
Positive influence
Negative influence

36. CIPRS: Stetler & Damschroder Theoretical Frameworks
PRISM: Practical, Robust
Implementation and Sustainability Model
4 Domains:
Intervention
Design
Recipients
External
Environment
Implementation &
Sustainability
Infrastructure
See references: Feldstein & Glasgow, 2008

37. CIPRS: Stetler & Damschroder Theoretical Frameworks
Implementation
Effectiveness 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.

38. CIPRS: Stetler & Damschroder Theoretical Frameworks
CFIR
Consolidated Framework for
Implementation Research
List of 39 constructs
that influence
implementation
No specific
relationships defined
Reflects theory from
multiple disciplines
and findings from
empirical researchCodeTopic/Description
I. INTERVENTION CHARACTERISTICS
A Intervention Source
B Evidence Strength & Quality
C Relative advantage
D Adaptability
E Trialability
F Complexity
G Design Quality and Packaging
H Cost
II. OUTER SETTING
APatient Needs & Resources
BCosmopolitanism
CPeer Pressure
DExternal Policies & Incentives
III. INNER SETTING

AStructural Characteristics
BNetworks & Communications
CCulture
DImplementation Climate
1Tension for Change
2Compatibility
3Relative Priority
4Organizational Incentives & Rewards
5Goals and Feedback
6Learning Climate
DReadiness for Implementation
1Leadership Engagement
2Available Resources
3Access to knowledge and information
IV. CHARACTERISTICS OF INDIVIDUALS
A Knowledge & Beliefs about the Intervention
B Self-efficacy
C Individual Stage of Change
D Individual Identification with Organization
E Other Personal Attributes
V. PROCESS
APlanning
BEngaging
1Opinion Leaders
2Formally appointed internal implementation
leaders
3Champions
4External Change Agents
CExecuting
DReflecting & Evaluating
See references: Damschroder et al. Under Review.

39. CIPRS: Stetler & Damschroder Theoretical Frameworks
Dual QUERI Objectives: Revisited
Generalize knowledge about how
to implement and sustain
interventions
Replicate successful
implementation

40. CIPRS: Stetler/Damschroder, Theoretical Frameworks
Selecting &Using a
Theoretical Framework

41. CIPRS: Stetler & Damschroder Theoretical Frameworks
Uses/Potential Value [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
importanceand 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

42. CIPRS: Stetler & Damschroder Theoretical Frameworks
Specific Selection and Use:
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]

43. CIPRS: Stetler & Damschroder Theoretical Frameworks
“Theoretical” 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]

44. CIPRS: Stetler & Damschroder Theoretical Frameworks
Specific Selection and Use:
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

45. CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Use
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?

46. CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Use cont’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/focusof change: Awareness, knowledge, skills,
self-perception, attitude, behavior, systems, structures, etc.
Given this information, have potentially influential factors
been clearly identified?

47. CIPRS: Stetler & Damschroder Theoretical Frameworks
Project: Theory Selection and Use cont’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 usefulnessfor your issue
3.Assess “fit” of these various frameworks and make
selection/s of one or more, as appropriate

48. CIPRS: Stetler & Damschroder Theoretical Frameworks
4.Plan your implementation project in
context of the selected framework
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?)

49. CIPRS: Stetler & Damschroder Theoretical Frameworks
4.Plan…cont’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.

50. CIPRS: Stetler & Damschroder Theoretical Frameworks
Application 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

51. CIPRS: Stetler & Damschroder Theoretical Frameworks
Challenges of Understanding
the Black Box
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

52. CIPRS: Stetler & Damschroder Theoretical Frameworks
QUERI’s Dual Function
Improve practice through scientifically-
based implementation
Increase understanding of
implementation science

53. CIPRS: Stetler & Damschroder Theoretical Frameworks
DISCUSSION/REACTION FORM