# Presentation: 514948

## CFIR Implementation Framework and Application to the VISN 11 Stroke Collaborative 

**Laura J. Damschroder, MS, MPH**
- Diabetes QUERI Co-IRC
- Ann Arbor Center for Practice Management & Outcomes Research
- &
**Teresa Damush, PhD**
- Stroke QUERI IRC
- VA HSRD Center of Excellence on
-    Implementing Evidence-Based Practice, Roudebush VAMC

**Notes:**
Strength, limitation, key guidance on evaluation 

Cheryl’s outline for individual presentations:

Development/scientific base
Major domains/elements:
Projected nature of its use 
Potential influence in implementation research
How the framework has been and/or could be evaluated
Example of use 

## Consolidated Framework for Implementation Research (CFIR)

- A comprehensive framework to promote consistent use of constructs, terminology, and definitions
- Consolidate existing models and frameworks
- Comprehensive in scope
- Tailor use to the setting

**Notes:**
Cheryl’s outline for individual presentations:

Development/scientific base
Major domains/elements:
Projected nature of its use 
Potential influence in implementation research
How the framework has been and/or could be evaluated
Example of use 

## Consolidated Framework for Implementation Research (CFIR)

- Hard Core

- Soft Periphery

- Hard Core

- Soft Periphery

- External Context

- Internal Context

- Intervention at Time**0**

- Intervention at Time**1**

- Intervention

- Intervention

## Consolidated Framework for Implementation Research (CFIR)

- Hard Core

- Soft Periphery

- Hard Core

- Soft Periphery

- External Context

- Internal Context

*Process*

- Intervention at Time**0**

- Intervention at Time**1**

*Process over Time*

- Intervention

- Intervention

## Dependent Variable of Interest

- Implementation
- The process of putting an intervention into use in an organization
- The vehicle by which a new practice is assimilated into an organization
- Fidelity
- Degree to which an intervention or program is delivered as intended
- Implementation Effectiveness
- Three general categories:
- Widespread avoidance (non-use)
- Meager and unenthusiastic use (compliant use)
- Skilled, enthusiastic, consistent use (committed use)

## Application of the CFIR

- Consists of 31 individual constructs
- Cannot use them all in every study
- And not all will apply
- A priori assessment of which constructs to include
- Modifiable & non-modifiable constructs
- Determine levels at which each construct may apply
- E.g., teams, departments, clinics, regions

## VISN 11 Stroke Collaborative

- VISN 11 Administration/CMO initiated an Acute Stroke Care QI project
- Asked VA Stroke QUERI Center for assistance
- Each of 7 VA sites identified clinical champion and QI team
- Partnered with COE Health Care System Redesign expert, Heather Woodward-Hagg

**Notes:**
Good Morning, we applied the CFIR to our Quality Improvement Project, The VISN Stroke Collaborative. In 2007, VISN11 administrators (CMO) and facility administrators decided to target acute stroke care processes for improvement within the 7 VA facilities spanning Indiana and Michigan. They asked the Stroke QUERI for assistance. Each site identified a stroke clinical champion and a quality improvement team. In addition, we partnered with a Health Care System Redesign expert, Ms. Hagg from the Indianapolis VA.

## VISN 11 Stroke Collaborative

- 3 Day Summit – Trained QI teams in LEAN  methodology to conduct Rapid
-    Improvement Projects
- Teams collectively voted to:
- Implement electronic stroke order sets in ED and Admissions
- Target 2 JC acute stroke care processes
- Lipid Management
- Dysphagia Screening

**Notes:**
We brought all teams to a 3 day summit and trained them in LEAN Healthcare System Redesign methodology to conduct rapid improvement projects. The teams collectively voted to implement electronic stroke order sets in ED and Admissions and to target 2 Joint Commission acute stroke care processes.

## FAB Model-Facilitating the Adoption of Best Practices

- Based upon Diffusion of Innovations, Translation Model, and Social Learning Theory

**Notes:**
To guide our intervention we developed a framework that illustrated our implementation methods. It is based upon the Diffusion of Innovations, the Iowa Translation Model and Social Learning Theory.

## Methods: QI project 

- Methods: QI project

- Use of Sharepoint Site
- Training Resources- LEAN
- Tools for Sites
- Examples of Administration letters
- CAC protocols for Stroke Order Sets
- Social Marketing – Stall Street Journal
- External Facilitation: Bi-weekly Coaching
- All 7 sites monthly call
- One on one coaching as needed
- Networking: Within and Between Sites
- Monthly QI data reported on 2 JC processes

**Notes:**
To facilitate change, the Stroke QUERI created and managed a sharepoint site stocked with resources and tools for the teams. Teams shared materials and tools by posting on this site and reported monthly quality performance on the 2 Joint Commission stroke care processes. In addition, we provided bi weekly coaching calls with the site teams and teams shared their barriers and strategies to overcome.

## Methods: Evaluation

- Quantitative
- % improvement on 2 JC stroke care processes
- Dose of biweekly coaching
- Qualitative
- Evaluate the FAB Domains
- Barriers and Facilitators of Implementation
- Analyze contents of biweekly coaching calls

**Notes:**
We are in the process of evaluating the collaborative implementation efforts that ran from April through November 2008. We are in the field conducting semi structured interviews with the teams to evaluate the FAB domains, the barriers and facilitators of implementing the stroke order sets and tools to improve the 2 JC processes. We are also plan to analyze the contents of biweekly coaching calls.

## Application of CFIR

- Paucity of implementation measures
- Used the CFIR as a resource for constructing semi structured interviews of FAB domains with 7 QI teams
- Incorporated measures/questions from previous work and mixed with items from CFIR and reviewed with Laura.

**Notes:**
As discussed this week, there is a paucity of implementation measures. We used the CFIR as a resource for measuring some of the FAB model domains.

## CFIR Application

- Communication and Diffusion Networks
- Key components of the colloborative intervention – Training summit, coaching calls, shared resources on listserv
- Viewed the teams as change agents who would return to facility and diffuse the innovation to peers.
- In CFIR, described as “Social Capital”
- Internal bonding -relationships within site
- External bridging – relationships across sites

**Notes:**
As an example, the Facilitation component was key to our program including the training, networking, coaching calls, and communication between sites. In CFIR, this is described as Social Capital as internal bonding and external bridging.

## CFIR Application (continued)

- We asked questions
- Communications within teams
- Communications to other units
- Communication with administration
- Communication with other 6 sites
- Asked about frequency
- Record of coaching call attendance

**Notes:**
We are asking questions about the frequency of communication and interactions within and across sites, we ask about unit cohesion and interactions with administration.

## CFIR Application: Implementation Process

- Innovation may not be used daily because of stroke volume – thus, difficult to observe
- Implementation processes
- process maps
- PDSA plans
- Listed possible processes, date of implementation, and degree of implementation 1-10 (CFIR)
- Locally tailored stroke order set (CAC –VISN/QUERI)
- Gained dept and admin approvals
- Trained staff and implemented order sets
- Addressed barriers – night staff not trained

## Conclusions:  CFIR...

- Embraces, consolidates, and standardizes key constructs from other models
- Agnostic to specific models and theories
- Provides a pragmatic structure for evaluating complex implementations
- Helps to organize findings across disparate implementations
- Paves the way for cross-study research

## Next Steps

- Continue to evaluate usefulness of the CFIR
- Is terminology/language coherent?
- Does it promote comparison of results across settings and studies over time?
- Does it stimulate new theoretical developments?
- Build database of evidence
- Shared Wikipedia of definitions and evidence
- Factor analysis of findings to consolidate constructs and facilitate subsequent analyses (fewer variables, greater power)
- Promote use by QUERIs

## Contact Info 

- Laura Damschroder
- _[Laura.Damschroder@va.gov](mailto:Laura.Damschroder@va.gov)_
- 734-845-3603
- Teresa Damush
- _[tdamush@iupui.edu](mailto:tdamush@iupui.edu)_
- _[Teresa.Damush@va.gov](mailto:Teresa.Damush@va.gov)_
- 317-988-2258

**Notes:**
In summary, the CFIR offers implementation researchers a resource operationalizing implementation domains. 
I apologize that I must return to the self-management workshop next door but I would be happy to discuss later and list my contact information.
Thank you.