Fostering Implementation of Health Services Research Findings into Practice: A Consolidated Framework for Advancing Implementation Science

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S.R., Alexander, J. A. & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), pp. 50 doi:10.1186/1748-5908-4-50
Background: Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework for Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.
Methods: We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.
Results: The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.
Conclusion: The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
The authors describe a Consolidated Framework for Implementation Research. It’s kind of a systematic review but not quite. They returned to a few systematic reviews and theory papers as a starting point then used a snowball sampling method and also solicited articles from colleagues to identify papers that presented conceptual models or frameworks of “determinants of diffusion, dissemination, and implementation of innovations in health service delivery and organization.” They then synthesized the elements (or “constructs” as used in the paper) of all those models arising from the 86 citations to identify commonalities that they call the Consolidated Framework for Implementation Research (CFIR). “The CFIR specifies a list of constructs within general domains that are believed to influence (positively or negatively, as specified) implementation, but does not specify the interactions between those constructs.” That means that the authors have indicated what domains and constructs are common between models of implementation science but they don’t presume to say how these constructs work (or not) together.
Implementation Science? I think it’s time for a definition.  Is this just another term for KT, KTT, KTE, KM, KMb, KI or K*?  No, I don’t think so. The authors define Implementation as “the constellation of processes intended to get an intervention into use within an organization; it is the means by which an intervention is assimilated into an organization. Implementation is the critical gateway between an organizational decision to adopt an intervention and the routine use of that intervention; the transition period during which targeted stakeholders become increasingly skillful, consistent, and committed in their use of an intervention. Implementation, by its very nature, is a social process that is intertwined with the context in which it takes place.” Based on this I think Implementation is an element within the broad spectrum of knowledge mobilization (KMb) that turns research into action for the benefit of society. KMb starts with creating relationships between researchers and decision makers so that research can ultimately inform decisions about interventions. As the authors define it, the decision to test, evaluate, adapt and then adopt that intervention is Implementation. It fits within the KMb spectrum, is downstream from many KMb activities such as relationship building, co-creation and systematic reviews. It is part of but is not synonymous with KMb.
Having reviewed all their models, the authors identify five major domains that are common to models of Implementation: 1) characteristics of the intervention; 2) outer setting; 3) inner setting; 4) individuals involved 5) implementation process. Theses domains are then broken down into constructs (and some into sub-constructs) as shown in the table below.  In the paper each construct is explained in detail.  They are presented here as an overview.

Domain Constructs
  1. Characteristics of the Intervention
Intervention source
Evidence strength and quality
Relative advantage
Design quality and packaging
  1. Outer Setting
Patient needs and resources
Peer pressure
External policies and incentives
  1. Inner Setting
Structural characteristics
Networks and communications
Implementation Climate

  1. Tension for change
  2. Compatibility
  3. Relative priority
  4. Organization incentives and rewards
  5. Goals and feedback
  6. Learning climate
Readiness for implementation

  1. Leadership engagement
  2. Available resources
  3. Access to information and knowledge
  4. Individuals involved
Knowledge and beliefs about the intervention
Self efficacy
Individual Stage of change
Individual identification with the organization
Other personal attributes
  1. Implementation process

  1. Opinion leaders
  2. Formally appointed implementation leaders
  3. Champions
  4. External change agents
Reflecting and evaluating

*Cosmopolitanism: the degree to which an organization is networked with other external organizations
Key Points for Discussion

  1. Implementation, like KMb, is social in nature. See Sandra Nutley’s seminal book, Using Evidence, for more discussion on the social nature of research utilization. Another commonality with KMb is that Implementation is based on relationships. “Complexity theory posits that relationships between individuals may be more important than individual attributes and building these relationships can positively influence implementation.” The social and relational nature of Implementation and KMb has two practice implications: A) Examine your KMb practice and determine if any of the constructs above might apply then think about how you maximize those than enable and minimize those that are barriers to effective KMb practice (but note point 2 below); B) Because KMb is social and relational you should maximize the attention paid to interactive engagement strategies and minimize (but don’t ignore) elements of producer push and the dissemination of knowledge products such as clear language research summaries.
  2. This paper (and many others, especially from the KT literature) make KMb sound very complicated. The authors advise us that “the constructs described in the CFIR represent a beginning foundation for understanding implementation. Implementation researchers should assess each construct for salience, carefully adapt and operationalize definitions for their study (paying special attention to sometimes indistinct boundaries between constructs), discern the level(s) at which each should be evaluated and defined (e.g., individuals, teams, units, clinics, medical centers, regions), decide how to measure and assess, and be aware of the time points at which measurement and evaluation occurs while acknowledging the transient nature of the state of each of these contextual factors.” I often think that what we do at York’s KMb Unit – brokering researcher/decision maker relationships – is not rocket science but then I read this degree of complexity.  I struggle with reconciling something that is not rocket science with something that engages along many of these constructs to reduce the risk of researchers and decision makers forming productive relationships.
  3. The papers reviewed were limited to health service delivery and organization. How do you think these constructs would translate into agriculture, education or climate change settings?

On point #2, do not get scared off. KMb is like dating. We do a lot of dating-like activities to get researchers and decision makers working together.  There are elements of a singles bar (KM in the AM), Lava Life (yaffle), calling cards (ResearchSnapshot) and a yenta (knowledge brokers, as mentioned in an old Mobilize This! blog). We’ve all been on dates but if we think about how complex it is to not only have a successful date but to take that to a long term relationship we would be afraid to date.  You’re not afraid to date (well…maybe…).  And you shouldn’t be afraid of KMb.  It is complex – that’s for the KMb/KT (etc) researchers to figure out.  But it’s not rocket science – that’s where practitioners come in and just do it.
Thanks to Melanie Barwick (@MelanieBarwick) for bringing this paper to my attention.
ResearchImpact-RéseauImpactRecherche (RIR) is producing this journal club series as a way to make evidence on KMb more accessible to knowledge brokers and to create on line discussion about research on knowledge mobilization. It is designed for knowledge brokers and other knowledge mobilization stakeholders. Read this open access article. Then come back to this post and join the journal club by posting your comments.