CFIR Implementation Framework withApplication to the VISN 11 Stroke Collaborative 

Laura J. Damschroder, MS, MPH

Diabetes QUERI Co-IRC

Ann Arbor Center for Practice Management & Outcomes Research

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Teresa Damush, PhD

Stroke QUERI IRC

VA HSRD Center of Excellence on

   Implementing Evidence-Based Practice, Roudebush VAMC

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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

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Inner Setting

Outer Setting

Consolidated Framework for Implementation Research (CFIR)

Inner Setting

Consolidated Framework for Implementation Research (CFIR)

Outer Setting

Inner Setting

Outer Setting

Core Components

Adaptable Periphery

Consolidated Framework for Implementation Research (CFIR)

Intervention

(unadapted)

Inner Setting

Outer Setting

Core Components

Adaptable Periphery

Core Components

Adaptable Periphery

Consolidated Framework for Implementation Research (CFIR)

Intervention

(unadapted)

Intervention

(adapted)

Consolidated Framework for Implementation Research (CFIR)

Core Components

Adaptable Periphery

Outer Setting

Inner Setting

Intervention

(unadapted)

Intervention

(adapted)

Process

Individuals

Involved

Core Components

Adaptable Periphery

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Application of the CFIR
        - Consists of 39 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

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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 a clinical champion and QI team
        - Partnered with COE Health Care System Redesign expert, Heather Woodward-Hagg

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.

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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 – tailor to their site
        - Target 2 JC acute stroke care processes 
        - Lipid Management
        - Dysphagia Screening

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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.

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Selecting a Theory – VISN 11
        - Consider Context
        - Study characteristics – Implementation study within a Quality Improvement initiative from VISN leadership
        - Professional discipline/perspective – Interdisciplinary groups
        - Intervention characteristics – Multiple stages and a combination of methodologies included in the intervention
        - Inner and outer setting – Structure of stroke care varied across sites
        - Individuals involved –Clinical teams, CACs, QUERI Researchers, Administrators
        - Implementation process- PDSA cycles, stroke order sets, training, policy changes, social marketing  
        - Consider Level
        - Individuals –coached individual team members
        - Teams – targeted clinical teams across 7 VA sites
        - Organization-VISN leadership supported this initiative
        - System

Project: Theory Selection and Use 

1.  Your targeted EBP recommendation: We

Explore others’ relevant experiences and results  :

Based upon previous learning collaboratives, lack of external facilitation was identified as a barrier to successful implementation after collaborative participation. Thus, the Stroke QUERI planned to provide this needed intervention element.

What related barriers, facilitators, determinants have been identified?

Access to Clinical Application Coordinators was identified by the clinical groups as a barrier to implementing a stroke order set. Thus, the VISN coordinated access to a CAC for each site. Some CACs were shared across sites and the VISN/Stroke QUERI facilitated CAC collaboration to locally tailor and implement a stroke order set.

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.

We reviewed existing theories and models across disciplines to guide our Stroke Collaborative intervention and implementation strategies. Existing models guided parts of our intervention but we did not find any that appeared to encompass the entire process and impact of implementation and organization change. For example, the PARIHS model includes perceptions of evidence, facilitation and context but it did not specify how the implementation should be planned, organized, and scheduled. Moreover Rogers’ Diffusions of Innovations model encompasses social learning across an organization but does not specify facilitation. Thus, we chose to develop a model that includes elements of PARIHS (e.g., External and Internal Facilitation); LEAN Six Sigma improvement processes (PDSA cycles); Diffusions of Innovation for the spread of the learning collaborative within and across sites; and the Iowa Model to depict the translation of evidence into practice across a social system among its users.

Selecting a Theory
        - USE:
        - Specify the elements of the collaborative intervention
        - Specify the external/internal facilitation
        - Specify diffusion of innovation across sites
        - Specify strategies to address barriers
        - Assess effects on adoption and maintenance
        - Tie Processes to Outcomes

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Selecting a Theory
        - Hypothesis generation
        - Clinical teams that engage in PDSA cycles will improve quality performance on 2 JC indicators compared to those who do not engage.
        - Clinical teams that participate in the external facilitation coaching calls will improve quality performance on 2 JC indicators compared to those who do not participate.
        - Successful implementation strategies will spread to other clinical practices.

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FAB Model-Facilitating the Adoption of Best Practices

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

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

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Methods: QI project-1 
        - Use of Sharepoint Site
        - Training Resources- LEAN
        - Tools for Sites

Examples of Administration letters

Examples of MOU for policy changes

CAC protocols for Stroke Order Sets

Social Marketing – Stall Street Journal

Training – how to screen for dysphagia

Training – how to use Stroke Order Set in CPRS

I split this slide into two...

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.

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Methods: QI project-2 
        - 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

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.

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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

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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.

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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.

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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.

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CFIR Application
        - Communication and Diffusion Networks
        - Key components of the collaborative 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

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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.

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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

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

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CFIR Application: Implementation Process
        - Innovation may not be used daily because of stroke volume – thus, difficult to observe
        - Implementation processes
        - process maps of stroke care processes
        - 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
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Dependent Variable of Interest
        - Implementation
        - Implemented a stroke order set
        - Implemented a training program
        - Fidelity
        - Degree to which an intervention is delivered as intended- #PDSA cycles; # coaching calls
        - Implementation Effectiveness
        - Widespread avoidance (non-use)
        - Meager and unenthusiastic use (compliant use)
        - Skilled, enthusiatic, consistent use (commited use) 

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Processes
        - 6/7 sites developed and implemented stroke order set
        - PDSA cycles ranged from 1 to 15 (m=4)
        - Participation in coaching calls ranged from 22 – 100% (m = 64%)
        - 3/7 spread intervention methods to other QI areas.
        - *Spread was seen among teams with highest fidelity.

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Outcomes
        - We found clinically significant improvements in 2 stroke performance measures by end of 6 month collaborative
        - 22% improvement dysphagia screening
        - 4% improvement in lipid management

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

INTERVENTION – Evidence BuildingFace Validity

INTERNAL CONTEXTFace Validity

Inner Setting

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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
        - 734-845-3603
        - Teresa Damush
        - Teresa.Damush@va.gov
        - 317-988-2258

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