Implementation Research Theoretical Frameworks CyberSeminar Series 4-Part Series: April 7 April 14 May 5 May 12 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

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

MAY Jeffrey Smith Applying the CFIR Dialogue with Presenters 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 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 12th session Send as early as possible to: cheryl.stetler@comcast.net CIPRS: Stetler & Damschroder Theoretical Frameworks

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

Foundations Terminology Theory Theoretical/conceptual framework Model 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) 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” 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) 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) CIPRS: Stetler & Damschroder Theoretical Frameworks

No Commonality… Illustration1! Conceptual models Theories of change Frameworks May have a preference based on your discipline or doctoral program background CIPRS: Stetler & Damschroder Theoretical Frameworks 1. Ref: Graham & Tetroe, in press

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

Why “Theory”: QUERI Dual Objectives 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

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

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

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

Selecting a Theory - 1 Consider Context Consider Level Study characteristics Professional discipline/perspective Intervention characteristics Inner and outer setting Individuals involved Implementation process Consider Level Individuals Teams Organization System CIPRS: Stetler & Damschroder Theoretical Frameworks

Selecting 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 CIPRS: Stetler & Damschroder Theoretical Frameworks 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.

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 CIPRS: Stetler & Damschroder Theoretical Frameworks

TYPES: Process Theories 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 These are steps you should be doing, regardless of implementation. Some are more likely to get into the black box than others… See references: Graham & Tetroe, in press Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103. Grol, et al. 2007 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. Stetler C. Updating the Stetler model of research utilization to facilitate evidence-based practice. Nurs Outlook 2001;49/6, 272-278. CIPRS: Stetler & Damschroder Theoretical Frameworks

Ottawa Model of Research Use Action-oriented Prescribes 3 main steps Assess Monitor Evaluate CIPRS: Stetler & Damschroder Theoretical Frameworks Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.

Framework of Dissemination in Health Services Intervention Research Crosses into impact theory – not a neat categorization. CIPRS: Stetler & Damschroder Theoretical Frameworks Mendel et al, 2008

2001 CIPRS: Stetler & Damschroder Theoretical Frameworks

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

Individual Level: 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 list 11 different models… CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007

Social Cognitive Theory 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. Organizational Setting CIPRS: Stetler & Damschroder Theoretical Frameworks http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/

Theory of Planned Behavior Motivational theory One variation of SCT  applied to professional/staff change; TPB is most common across 76 studies reviewed in Godin, et al Grimshaw and Eccles using – esp. independent physicians. CIPRS: Stetler & Damschroder Theoretical Frameworks 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

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

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

Impact Theories - 3 Organizational Context Theories Innovative organizations Quality management Integrated care Complexity Organizational learning Organizational culture Political & Economic Context Theories Reimbursement Contracting CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007.

Roger’s Theory of Diffusion Characteristics of the intervention Organizational characteristics Effective implementation Adoption decision Outcomes Environmental context 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. Control 2006;34(8):507-12. CIPRS: Stetler & Damschroder Theoretical Frameworks

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

PARiHS Framework 3 major domains Positive influence 3 major domains Evidence Context Facilitation Continuums of high and low values that interrelate to influence implementation Low Evidence High Context Facilitation Parsimony – vs. Greenhalgh; balance with how much to put in Footnotes Negative influence CIPRS: Stetler & Damschroder Theoretical Frameworks Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual. Health Care 1998;7(3):149-58.

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

Implementation Effectiveness Model Quantitative measures of predictors of implementation effectiveness Strength of relationships empirically estimated Homogeneous constructs reflecting shared values org-wide or distinct groups of targeted users. CIPRS: Stetler & Damschroder Theoretical Frameworks Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. J Appl Psychol. 2001;86(5):811-824.

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 research CIPRS: Stetler & Damschroder Theoretical Frameworks See references: Damschroder et al. Under Review.

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

Selecting & Using a Theoretical Framework 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 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

Specific Selection and Use: QUERI Centers 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] CIPRS: Stetler & Damschroder Theoretical Frameworks

“Theoretical” Selection “QUERI” Evaluation: In-depth understanding Theory criteria Overall strengths Overall limitations Missing elements [QUERI PDI Working Group] Origins of the framework Meaning of the framework Logical consistency Generalizability Parsimony Testability Usefulness [Grol et al., 2007] CIPRS: Stetler & Damschroder Theoretical Frameworks

Specific Selection and Use: QUERI Projects 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 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? 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/focus of change: Awareness, knowledge, skills, self-perception, attitude, behavior, systems, structures, etc. Given this information, have potentially influential factors been clearly identified? CIPRS: Stetler & Damschroder Theoretical Frameworks

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

Plan your implementation project in context of the selected framework 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?) 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 Test hypothesis that sites with an external facilitator will be more successful than comparison sites under analogous conditions of limited resources and passive leadership. CIPRS: Stetler & Damschroder Theoretical Frameworks

Application Examples April 14: May 5: Applying a Framework Phil Ullrich A Mixed-model Approach-Intro Jeffrey Smith May 5: A Mixed-model Approach-Cont. Applying the CFIR Laura Damschroder & Teresa Damush 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

QUERI’s Dual Function Transparent Selection, Use, Evaluation & Explicit Reporting of THEORETICAL FRAMEWORKS Improve practice through scientifically-based implementation Increase understanding of implementation science CIPRS: Stetler & Damschroder Theoretical Frameworks

DISCUSSION/REACTION FORM CIPRS: Stetler & Damschroder Theoretical Frameworks