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

2. 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

3. 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

4. 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

5. 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:
CIPRS: Stetler & Damschroder Theoretical Frameworks

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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.

15. 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

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

17. 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

18. 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

19. 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

20. 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):

21. 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

22. 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):
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,
CIPRS: Stetler & Damschroder Theoretical Frameworks

23. 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):

24. 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

25. 2001
CIPRS: Stetler & Damschroder Theoretical Frameworks

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

27. 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

28. 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

29. 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: l

30. 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.

31. Social Network Theory Tailor engagement strategy to social networks
CIPRS: Stetler & Damschroder Theoretical Frameworks

32. 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.

33. 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):
CIPRS: Stetler & Damschroder Theoretical Frameworks

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

35. 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):

36. 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

37. 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):

38. 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.

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

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

41. 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

42. 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

43. “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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

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