# Presentation: 468878

## Implementation Research Theoretical FrameworksCyberSeminar Series 

**	****	****	****4-Part Series:**
**April 7**
**April 14**
**May 5**
**May 12**

## Objectives

- Purpose/potential value and uses
- Process for selection and use
- Nature and underlying rationale of specific frameworks/approaches
- Evaluation

## APRIL

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

## 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**

## 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:*
- _[cheryl.stetler@comcast.net](mailto:cheryl.stetler@comcast.net)_* *

## Foundations

- What are implementation “theories”?
- How and why are they useful?

## Foundations Terminology

**Theory**
**Theoretical/conceptual framework**
**Model**

## 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)

## 															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*”

## 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)

## 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)

## No Commonality... Illustration1!

**Conceptual models **
*Theories of change*
*Frameworks*

- 1.** **Ref: Graham** **& Tetroe, in press

**Notes:**
May have a preference based on your discipline or doctoral program background

## Why “Theory”?

**Theories, models, frameworks provide a **_**systematic**_** method:**
**	**** ... ****for identifying, understanding, operationalizing & evaluating the ****black box**** phenomenon =**
**“****IMPLEMENTATION****”**
**	****	**

## 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 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***

## QUERI Dual Objectives

**Replicate successful implementation**
**Help navigate complexity of implementation & sustainability**
**Tailor essential factors to fit the context**

## Using Theory for Implementation Planning

- Select theory of planned behaviorchange

- Assess fit with initial theory

- Identify potential strategies for achieving change

- Select interventionsthat fit with plannedstrategies (based on theory)

- Identify interventiontools that fit bothstrategy and theory

- Launch interventionusing identified toolsand strategies

- Evaluate effectivenessof intervention,strategies, tools

- See references:  Sales et al., 2006

## Using Theory for Implementation Planning

**Using Theory for Implementation Planning**

- See references:  Sales et al., 2006

- Assess fit with initial theory

- Identify potential strategies for achieving change

- Select interventionsthat fit with plannedstrategies (based on theory)

- Identify interventiontools that fit bothstrategy and theory

- Launch interventionusing identified toolsand strategies

- Evaluate effectivenessof intervention,strategies, tools

**Select theory of ****planned behavior****change**

**Theories**

**Models**

**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

## 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

- _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

## 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*

- 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.

**Notes:**
These are steps you should be doing, regardless of implementation. Some are more likely to get into the black box than others...

## 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.

## Framework of Dissemination in Health Services Intervention Research

- Mendel et al, 2008

**Notes:**
Crosses into impact theory – not a neat categorization.

## 2001

## Impact Theories - 1

- Individual-level theories
- Stage of change
- Cognitive
- Educational
- Motivational

- Grol et al, 2007

## Individual Level: Stage of Change

- 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, 2007

**Notes:**
Grol, et al list 11 different models...

## 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.

- 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%20clusters/Health%20Communication/Social_cognitive_theory.doc/

**Organizational Setting**

## 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.htm](http://people.umass.edu/aizen/tpb.diag.htm)_ l

**Notes:**
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.

## Impact Theories - 2

- Social context theories
- Social Marketing
- Social learning
- Communication
- Social network & influence
- Teamwork
- Professional development
- Leadership

- Grol et al, 2007.

## Social Network Theory

**Social Network Theory**

- Tailor engagement strategy to social networks

- _[http://www.istheory.yorku.ca/socialnetworktheory.htm](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

- Grol et al, 2007.

## 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. Control* 2006;34(8):507-12.

## Greenhalgh, et al’s Conceptual Model

## PARiHS Framework

**PARiHS **_**Framework**_

- 3 major domains
- Evidence
- Context
- Facilitation
- Continuums of high and low values that interrelate to influence implementation

- Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. *Qual. Health Care* 1998;7(3):149-58.

**Positive influence**

**Negative influence**

**Notes:**
Parsimony – vs. Greenhalgh; balance with how much to put in
Footnotes

## PRISM: Practical, Robust Implementation and Sustainability Model

- 4 Domains:
- Intervention Design
- Recipients
- External Environment
- Implementation & Sustainability Infrastructure

- See references: Feldstein & Glasgow, 2008

## 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.

**Notes:**
Homogeneous constructs reflecting shared values org-wide or distinct groups of targeted users.

## 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

- See references: Damschroder et al. Under Review.

## Dual QUERI Objectives: Revisited

**Generalize knowledge about how to implement and sustain interventions**
**Replicate successful implementation**

## Selecting & Using a Theoretical Framework

** **

## 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**

## 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]*

## “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]

## 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*

## 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?

## 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?

## 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

## 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?*)

## 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.** *

## 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**

## 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

## QUERI’s Dual Function

- Improve practice through scientifically-based implementation
- Increase understanding of implementation science

**Transparent Selection, Use, Evaluation  & Explicit Reporting of THEORETICAL FRAMEWORKS**

- DISCUSSION/REACTION FORM