The Role and Selection 

Theoretical Frameworks 

Implementation Researc

Laura J. Damschroder, MS, MPH

Diabetes QUERI

Ann Arbor VA Center for Clinical Management Researc

June 7, 2012
Acknowledgements

• Funded by QUERI in VA• Invaluable collaboration over the years

– Brian Mittman

– Cheryl Stetler– Teresa Damush
Outline

• Why use theory?• Applying Theory in QUERI Step 3• Approach for selecting and applying the

– With example case study

• Resources and help
Session Objectives

• Understand the role & value of theory i

implementation research

• Equip you with an approach for applyin

theory in your work

– Study design & conduct– Grant writing
A word on THEORY

• A generalized, loose definition of theory 

science will sometimes be used today

– “A set of statements or principles devised 

explain a group of facts or phenomena”

1

• May be embodied in a framework, model, or s

hypothesis

• The literature is rife with inconsistent u

terms

– Frameworks, models, theories

1. The American Heritage Science Dictionary. http://dictionary.reference.com/browse/theory
My favorite working definit

• Framework

– A conceptual framework that identifies a set of variables an

relationships that should be examined to explain [impleme

– Need not ID direction of relationships nor critical hypothes

• Theory

– Denser and logically coherent set of relationships that can 

explanations and may or may not ID causal relationships

• Model

–

Precise assumptions about a limited set of parameters and 

– Usually multiple models are compatible with frameworks a

Kitson, A.L., et al., Evaluating the successful implementation of evidence into practice using the PARIHS framework: challenges. Implement Sci, 2008. 3(1): p. 1.

Theory in a Clinical Interven

• Example

– Weight Loss Intervention: ASPIRE-VA

• Social Cognitive Theory• Self

-Regulation Theory

• Problem-solving Theory• Small change Theory
Clinical Intervention Concep

Model

Motivation Level 

and Intention 

Satisfaction

Deprivation

Self-Efficacy

Intervent

S

Long-

Small Changes & 

Maintain New 

Behavior

Baseline 

Behaviors

(e.g. daily step 

count)

Demographic & 

Environmental 

Variables 

Self-Monitoring

Goal Setting

•Anchor/Guide•Relative to Baseline•Small•Self-Selected

ASPIRE-VA Grant #IBB 09-034
Theory in Implementatio

• Organizational Climate Theory• Theory of conformity• Other psychological & organizational th
Conceptual Model for Impleme

Resources Innovation- Values Fit Champion(s)

Management 

Support

Implementation 

Climate

Implementation 

Policy & Practices

Values Fit

Imple

Effe

Klein, K.J., A.B. Conn, and J.S. Sorra, Implementing computerized technology: An organizational analysis. Journal o

2001. 86(5): p. 811-824.Helfrich, C. D., Weiner, B. J., McKinney, M. M., & Minasian, L. (2007). Determinants of implementation effectiveneframework for complex innovations. Med Care Res Rev, 64(3), 279-303. 
Implementation Effectiveness

Pulling it Together

Resources

InnovationValues Fit Champion(s)

Intervention Effectiveness

Management 

Support

Implementation 

Climate

Implementation 

Policy & 

Practices
Type III Errors

• Incorrect conclusions about effectivene

intervention may result when – No treatment or too little treatment was a

provided – The wrong treatment was provided – Treatment is nonstandard, uncontrolled, oacross settings/population

• ...all resulting from inadequate impleme
Objectives of Implementa

Research

• Replicate successful implementation

• Core components• Rationale

• Generalize knowledge about how to 

implement and sustain interventions

• Navigate complex implementations

• Improve prospects for sustainability

Theory-driven implementation enables u

accomplish these objectives
State of the Literature - 

• Systematic reviews of interventions 

consistently show

– Some work some of the time

– None work all of the time– More research needed to figure out what 

where and why
State of the Literature – 

• Largely atheoretical

– Related to implementation

1

–

...and, by the way, too often, for interventiwell

• Theory used only as heuristic

2

– Dropped after the introduction– Used to organize discussion of findings
State of the Literature - 

• Inadequate descriptions of intervention

context, and implementation1-3

– Large majority of trials have no qualitative 

component

– Implementation studies suffer from small 

• Example from very recent paper:

4

– “Findings revealed limited information about attrib

successful and unsuccessful team initiatives, barriefacilitators to team initiatives, unique or combined contribution of selected interventions, or how to eestablish these teams.”
Theory as a Way Forwa

• “‘Generalization through theory’ potentia

offers a more efficient and appropriate megeneralization than study replication in mapossible settings” (p 2)

• International panel convened by AHRQ to improve the design, evaluation, and 

research for patient safety practices

– Build knowledge through strengthened confid

the usefulness of a theory

– Identify factors that predict likelihood of succ– Guide adaptation of the intervention and tailo

implementation

• Through knowledge of determinants – or levers – 
Case Example: MOVE!

®

• Step 1: Prevention is high priority (now T-21) is

– Obesity prevalence is high among Veterans

• Step 2: Disseminate the MOVE! Weight Manag

Program in January 2006

• Step 3A: Many facilities not reporting MOVE! W• Step 3D: ID barriers and facilitators of MOVE! 

implementation

2

• Embedded mixed methods cross-sectional study

1

• Purposive sample of 5 sites

– Maximize variation with respect to program volume

» Indicator of implementation effectiveness

• Semi-structured interviews with 24 stakeholders

– 83% of those contacted and invited, participated in the stud

19

1. Creswell, J.W. and V.L.P. Clark, Designing and Conducting Mixed Methods Research. 1st ed. 2007, Thousand Oaks, C

274.

2. Damschroder L, Goodrich D, Robinson C, Fletcher C, Lowery J. A systematic exploration of differences in contextual 

implementing the MOVE! weight management program in VA: A mixed methods study. BMC Health Services Resea
Guiding Theories

• Types of theories

– Explanatory Theories– Organizational-level theories

• Consolidated Framework for Implemen

Research (CFIR)

– Guided qualitative data collection & analy

• Model of Implementation Effectiveness

– Guided quantitative data collection & anal– Qualitative confirmation
CFIR – www.wiki.cfirwiki.net – Comprehensive framework to promote co

use of constructs, terminology, and definit

• Consolidates existing models and frameworks• Comprehensive in scope• Tailor its use to the study – Guided Qualitative Data Collection & Anal

Copy of the master interview guide available: http://wiki.cfirwiki.net/index.php?title=CFIR_in_action#Evaluatio
CFIR: 5 Major Domain

• Intervention

– 8 Constructs (e.g., evidence strength & quality, complexity)

• Outer Setting

– 4 Constructs (e.g., patient needs & resources)

• Inner Setting

– 14 constructs (e.g., leadership engagement, available resourc

• Individuals Involved

– 5 Constructs (e.g., knowledge, self-efficacy)

• Process

– 8 Constructs (e.g., plan, engage, champions)

22
Additional File 3: Short Defin

Ref: http://www.implementationscience.com/content/4/1/50
Model of Implementation Effect

• Implementation Framework for Comple

Innovations – Quantitative Data Collect

Resources Innovation- Values Fit Champion(s)

Management 

Support

Implementation 

Climate

Implementation 

Policy & Practices

Values Fit

Imple

Effe

Klein, K.J., A.B. Conn, and J.S. Sorra, Implementing computerized technology: An organizational analysis. Jo

Applied Psychology, 2001. 86(5): p. 811-824.
Quantitative Results

2345

Average Summary Scorea Facilities with Low 

01 Effectiveness

Facilities with HigImplementation E

Problem of sample (one facility was in 
Qualitative Results

• Importance of Champions was mixed

– Appointed but largely absent in one low and o

implementation site

• Innovations-values fit is important

– I would say 99.99%...of the providers recogniz

[obesity] is in some way hindering their succemanaging diabetes or managing blood pressumanaging hyperlipidemia...So everyone is verreceptive...to refer the patients to MOVE! [MCoordinator]

– Lack of fit at 2 low implementation sites
Theoretical Framework

• Implementation Framework for Comple

Innovations

Resources Innovation- Values Fit Champion(s)

Management 

Support

Implementation 

Climate

Implementation 

Policy & Practices

Values Fit

Imple

Effe
Were the theories usefu

• Implementation Framework for Comple

Innovations

Resources Innovation- Values Fit Champion(s)

Management 

Support

Implementation 

Climate

Implementation 

Policy & 

Practices

Values Fit

Imple

Effe

Damschroder L, Goodrich D, Robinson C, Fletcher C, Lowery J. A systematic exploration of differences in contextuato implementing the MOVE! weight management program in VA: A mixed methods study. BMC Health Services Re

2011;11(1):248.
Were the Theories Usefu

• Champions’ influence was mixed• Additional insights & constructs were 

identified through CFIR. E.g., 

–

“Teamness” mattered: the degree to whicMOVE! teams coalesced

– Perception of intervention characteristics

• Strength & Quality of evidence• Relative Advantage

– Perception of patient needs & resources

• Not all CFIR constructs were salient
Types of Theories

• Multiple theories often needed

– Explanatory theories (aka descriptive, impact)

• Hypotheses and assumptions about how 

implementation activities will facilitate a desirchange, as well as the facilitators and barriers success

– Process theories – (aka prescriptive, planned action

• How implementation should be planned, orga

scheduled

– Mixed theories

• Elements of both
Process: 

“4E’s” Translation Model

Ensure all patients receive the interv

ID Local Barriers 

to Implementation

Summarize 

the 

Evidence

Engage

to Implementation

Measure 

Performance

Ed

Execute

Evaluate

Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a moknowledge translation. BMJ. 2008;337:a1714.Used in the Michigan Keystone Project:Pronovost P. Interventions to decrease catheter-related bloodstream infections in the 

Intensive Care Unit Project. Am. J. Infect. Control. Dec 2008;36(10):S171 e171-175.Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter relatin Michigan intensive care units: observational study. BMJ.340:c309.
Mixed Model

Promoting Action on Research Implement

Health Services (PARIHS)

• Successful Implementation = 

f(Evidence,Context,Facilitation

• Quantitative Measurement

• Organizational Readiness for Change Assessment (OR• Alberta Context Tool

Estabrooks, C. A., J. E. Squires, et al. (2009). "Development and assessment of the Alberta Context Tool." BMC Health Serv 

•Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Q

1998;7(3):149-58.

•Helfrich CD, Damschroder LJ, Hagedorn HJ, et al. A critical synthesis of literature on the promoting action on research i

health services (PARIHS) framework. Implement Sci. 2010;5(1):82.

•Stetler CB, Damschroder L, Helfrich C, Hagedorn H. A Guide for Applying a Refined PARIHS Framework for Implementa

Implementation Science. 2011.

Helfrich C, Li Y-F, Sharp N, Sales A: Organizational readiness to change assessment (ORCA): Development of an 

based on the Promoting Action on Research in Health Services (PARiHS) framework. Implementation Science 2
Choosing Theory 

1. Consider nature of the theory

– Process v. explanatory– Context (e.g., policy, organization)– Discipline (e.g., social science, psychology)

2. Consider level at which it will be applied

– Individuals– Teams– Organization– System

3. Previous findings, experience4. Greatest potential for adding to the know

base
Multi-level Model

The Practical, 

Robust 

Implementation 

and 

Sustainability 

Model

Feldstein, A. C., & Glasgow, R. E. (2008). A practical, robust implementation and sustainability model (PRISM) foresearch findings into practice. Jt Comm J Qual Patient Saf, 34(4), 228-243.

Model

(PRISM)
Choosing Theory

Looking Forward from Step 3 Case 

1. Consider nature of the theory

– Used 2 Explanatory Theories

2. Future work: develop implementation str

– Consider level at which theory will be applied

• Organization

– Develop organizational strategy to implement MOVE

• Teams

– Importance of coalescing teams (“teamness”)

• Individuals

– Physician Champion– Formally appointed implementation leader

• System

– System-wide performance measurement
Conducting Theory-based

Step 4 Implementation Stud

Assess targeted 

EBP change and 

context

Use theory to 

Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findi

practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49.

Use theory to 

guide assessment
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale
QUERI Step 4

Implementation Researc

• Example Study: – Krein S, Bernstein S, Fletcher C, et al. Improving eye care for veterans with diab

using the QUERI steps to move from evidence to implementation: QUERI SeriesScience. 2008;3(1):18.

• Step 1: Preventable blindness in diabetes 

• Step 2: Early detection and timely laser th• Step 3: Lack of close follow-up• Step 4: Implement strategies to improve f

– System level: Change performance measures – Local organization: Progressive Reminder & S

System (PRSS)
Organization-level Theor
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Who needs to do what How can behavior (and 

Develo

imple

st

Who needs to do what 

differently?

Which barriers & facilitators 

need to be addressed?

What behavior chang

techniques (and org 

strategies) could overco

B&Fs?

How can behavior (and 

change be measured a

understood?

French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement esystematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24 2012;7(1):38.
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Who needs to do what How can behavior (and 

1. Providers need to 

document follow-up visit 1. Mailed Survey

Develo

imple

st

Who needs to do what 

differently?

Which barriers & facilitators 

need to be addressed?

What behavior chang

techniques (and org 

strategies) could overco

B&Fs?

How can behavior (and 

change be measured a

understood?

French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement esystematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24 2012;7(1):38.

document follow-up visit timeframe

2. Scheduler needs to 

schedule appointment

1. Heighten Tension for 

Change

2. Tools/processes for 

following up with patients

1. Policy level advocacy2. PRSS Tool

1. Mailed Survey2. Semi-structure Intervi
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st

Resources

• Selecting theories – Sharepoint site

• Classification of Theories• Example Theory Diagrams – Process Theories

• Selecting techniques/strategies – Organizational-level

• Powell BJ, McMillen JC, Proctor EK, et al. A compilation of stra

implementing clinical innovations in health and mental healtRes. Rev. Apr 2012;69(2):123-157 – Individual-level

• Michie S, Wren B, Williams S. Reducing absenteeism in hospit

staff: pilot of a theory based intervention. Occup. Environ. M2004;61(4):345-349. 
Using Theory: A Few Note

• “All models are wrong...must be alert to 

importantly wrong”

– There are no right or completely wrong the

George E P Box, in "Science and statistics", Journal of the American Statistical Association 1976 

• There are better fitting theories that ex

why a specific strategy or mechanism cthe intended change

• Implementation strategy(s) need to be 

operationalized from theoretical conce
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st

Execu

imple

st

Concurrent 

monitoring and 

refinement
Conducting Theory-based 

Implementation Studies

Assess targeted 

EBP change and 

context

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st

Execu

imple

st

Evaluate effectiveness

of implementation

strategy
Case Study: Effectivenes

Implementation Strateg

• It took 5 years to get the performance me

changed

– 2 years longer than planned

– Near the end of the study

• Mixed commitment and loss over time

– Pressure exerted by existing performance me– Technical issues with PRSS integration/use– Local priorities and feuds

• Lessons learned!
Conducting Theory-based 

Implementation

Assess targeted 

EBP change and 

context

Assess fit of 

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st

Assess fit of 

findings with 

initial theory

Execu

imple

st

Evaluate effectiveness

of implementation

strategy

Don’t skip this step
Conducting Theory-based 

Implementation

Assess targeted 

EBP change and 

context

Assess fit of 

Select targeted 

theory(s) & provide 

rationale

Develo

imple

st

Assess fit of 

findings with 

initial theory

Execu

imple

st

Evaluate effectiveness

of implementation

strategy

Add to the knowledge-base
Assess Theory 

• Was it useful?

– Does theory still apply?

• Modifications/refinements needed?• Building validity of theory(s)

– Quantitative theory testing

• Test hypotheses• Path analyses

– Qualitative theory testing

• Is terminology/language coherent?• Does it promote comparison of results across sett

studies over time?

• Does it stimulate new theoretical developments?
Key Points

• Use pre-implementation work to inform 

implementation approach

• Do use theory• Provide clear rationale for theory selection• Clearly define implementation strategy fo

replication beyond your specific efforts – Internal validity – External validity

• Evaluate usefulness of theory(s) used
Session Objectives

• Understand the role & value of theory i

implementation research

• Equip you with an approach for applyin

theory in your work

– Study design & conduct– Grant writing
The field is ripe

• Implementation Science is relatively ne

– What is the dependent variable?– How to measure?

– What is success

?

– Sustainability

• Mutable v. immutable variables
Help

• References in this presentation• CIPRS• QUERI Centers• Your EIS mentors

You are not alone
Additional References

ASPIRE-VA Theoretical Framework Slide: Damschroder, L. J., Lutes, L. D., Goodrich, D. E., Gillon, L., & Lowery, J. C. (2010). A small-change 

telephone promotes weight loss in veterans: Results from the ASPIRE-VA pilot study. Patient Education and Counseling, 79, 262-266. do& Lutes LD, Steinbaugh EK. Theoretical Models for Pedometer Use in Physical Activity Interventions. Physical Therapy Reviews. 2010;1

Type III Errors Slide: Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. Implementation Research: A Synthesis of the Literature. Tamp

Florida, Louis de la Parte Florida Mental Health Institute; December 27, 2007 2005.

State of the Literature – 2 Slides:1. Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices

care. Feb 11 2011.

2. Helfrich, C. D., Damschroder, L. J., Hagedorn, H. J., Daggett, G. S., Sahay, A., Ritchie, M., et al. (2010). A critical synthesis of literature on 

research implementation in health services (PARIHS) framework. Implement Sci, 5(1), 82. doi: 10.1186/1748-5908-5-82

State of the Literature – 3 Slides:1. Glenton, C., Lewin, S., & Scheel, I. B. (2011). Still too little qualitative research to shed light on results from reviews of effectiveness trials: A 

review on the use of lay health workers. Implement Sci, 6(1), 53. doi: 10.1186/1748-5908-6-53

2. Weiner, B. J., Amick, H. R., Lund, J. L., Lee, S. Y., & Hoff, T. J. (2011). Use of qualitative methods in published health services and manag

review. Medical Care Research and Review, 68(1), 3-33. doi: 10.1177/1077558710372810

3. Michie S, Abraham C, Eccles M, Francis J, Hardeman W, John S, Abraham C, Eccles M, Francis J, Hardeman W, Johnston M. Strengthening evaluation and implementation ston M. Strengthening evaluation and implementation by specifying compon

 by specifying compon

interventions: a study protocol. Implementation Science. 2011;6(1):10.

4. White, D. E., Straus, S. E., Stelfox, H. T., Holroyd-Leduc, J. M., Bell, C. M., Jackson, K., et al. (2011). What is the value and impact of quali

scoping review. Implement Sci, 6(1), 97. doi: 10.1186/1748-5908-6-97

Theory as a Way Forward Slide:1. Foy, R., Ovretveit, J., Shekelle, P. G., Pronovost, P. J., Taylor, S. L., Dy, S., et al. (2011). The role of theory in research to develop and e

patient safety practices. Qual Saf Health Care. doi: 10.1136/bmjqs.2010.047993 

2. Damschroder, L. J., & Hagedorn, H. J. (2011). A guiding framework and approach for implementation research in substance use disorde

Behav, 25(2). doi: 10.1037/a0022284

More on mixed methods: OBSSR Best Practices for conducting mixed methods research in Health Sciences: 

http://obssr.od.nih.gov/scientific_areas/methodology/mixed_methods_research/pdf/Best_Practices_for_Mixed_Methods_Research.pdf

Types of Theories Slide:Adapted from: Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M. Planning and studying improvement in patient care: the use of theore

2007;85(1):93-138.

Selecting Evidence-based Implementation StrategiesCochrane’s Effective Practice and Organization of Care (EPOC): http://epoc.cochrane.org/AHRQ’s Evidence-based Practice Centers: http://www.ahrq.gov/clinic/epc/
EIS Theory Team, Denver July 2010 

A CLASSIFICATION OF THEORIES

TYPES OF THEORY1,2 SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/SAMPLE C

PRESCRIPTIVE/PROCESS/PLANNED ACTION: 

 Outline for the user how 

implementation should be planned, organized and scheduled 

1. Ottawa model 

Graham ID, Logan J. Innovations in kno

of care. Can J Nurs Res 2004 Jun;36(2):

Logan J, et al. Evidence-based pressure-

model of research use. Can J Nurs Res. 

2. Precede-Proceed Green LW, Kreuter MW. Health promo

and Ecological Approach. 3 ed. MountaPublishing Company; 1999 

Abbott CA, et al. Adoption of a ventilat

clinical practice guideline. Worldviews 2006;3(4):139-52. 

3. Stetler model on research 

utilization/EBP

Stetler CB. Updating the Stetler Model 

facilitate evidence-based practice. Nurs Dec;49(6):272-9. 

Newell-Stokes V, et al. Developing an 

maintenance of central venous cathetersSep;15(5):199-204 

4. Technology transfer model Kraft JM, et al. A technology transfer m

interventions: science and practice. AIDSuppl):7-20. 

5. Ten-stage model Grol, R., Wensing M. 2004. What Drive

Incentives for Achieving Evidence-Base180(6):S57–S60.

1 Graham I, Tetroe J. Chapter 4.1. Theories of Knowledge to Action: Planned action theories. In Knowledge Translation in Health C

Practice, S Straus, J Tetroe, I Graham (Eds). 2009: Wiley Blackwell. 

2 Grol RP, et al. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85(1):93-
EIS Theory Team, Denver July 2010 

TYPES OF THEORY SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

EXPLANATORY/IMPACT/DESCRIPTIVE: 

 Describe and explain how change occurs, 

including related influences. Such theories can be used to develop hypotheses and assumptions about how implementation activities will facilitate a desired change, as well as related facilitators and barriers for success 

1. Diffusion of innovation [through 

communication channels in a social system] 

Rogers E. Diffusion 

Schuster, Inc., 2004. 

Krein SL, Olmsted R

Forman J, Banaszak-Hinfection prevention equantitative and qualiControl 2006;34(8):5

2. Unifying conceptual model for spread/ 

sustainability of innovations 

Greenhalgh T, et al. D

service organizationsrecommendations. M

Gask L, et al. Dissem

suicide prevention traBMC Health Serv Re

3. Implementation effectiveness • Klein KJ, et al. Imple

technology: An organPsychol. 2001;86(5):8

4. CFIR Damschroder LJ, et a

health services researconsolidated framewoimplementation scienAug7;4:50. 
EIS Theory Team, Denver July 2010 

TYPES OF THEORY SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

MIXED: 

 Reflect both process/planned action and 

descriptive/explanatory types of theories 

1. PARIHS 

• Kitson AL, et al. Eva

implementation of evPARiHS framework: challenges. Impleme

• Rycroft-Malone, J., e

factors that influence into practice. J Clin N

2. PRISM • Feldstein AC, Glasgo

implementation and sfor integrating researc

Comm J Qual Pat Saf 

3. Mendel • Mendel P, et al. Interv

community context: a evidence on disseminhealth services researMar 2008;35(1-2):21
EIS Theory Team, Denver July 2010 

LEVELS OF THEORY3,4 SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

INDIVIDUAL LEVEL CHANGE: 

1. “Motivational: theories to explain 

behaviour change in people who have 

not yet established an intention to engage in a particular behaviour” (Michie 

et al., 2005)5

2. “Action: theories to explain the behaviour 

of those who are motivated to change” 

(Michie et al., 2005)

1. Theory of planned behaviour 

• Ajzen I. The theory of 

Hum Decis Process. 19http://people.umass.ed

• Eccles M, et al.. Chang

professionals: the use ouptake of research find

Feb;58(2):107-12. 

2. Stages of change theories/ transtheoretical 

model 

• Pathman, D.et al. The 

Model of the Steps to CThe Case of Pediatric Med Care 1996;34:132

• Prochaska, J.O., and W

Transtheoretical ModeAmer J Health Prom 1

3. Social cognitive theory /self-efficacy 

• Godin G, et al. Healthc

and behaviours: A syston social cognitive the16;3:36. 

• Soumerai SB, Avorn J

outreach ('academic dedecision making. JAM

3 Michie S et al. Psychological Theory Group. Making psychological theory useful for implementing evidence based practice: a con

Health Care. 2005 Feb;14(1):26-33. 

4 Davies P, et al. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies a

rigorous evaluations. Implement Sci. 2010 Feb 9;5:14
EIS Theory Team, Denver July 2010 

LEVELS OF THEORY SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

INDIVIDUAL LEVEL CHANGE (cont’d) 

4. Decision theory • Bucknall T. A gaze thr

toward knowledge tran

Jul-Aug;56(4 Suppl):S

5. Social marketing • Luck J, et al. A social 

implementing evidencQUERI: the TIDES demodel. Implement Sci 

6. Learning/education theory • Merriam SB. Andrago

pillars of adult learning 

Adult and Continuing © Jossey-Bass, A PublSons, Inc. 
EIS Theory Team, Denver July 2010 

LEVELS OF THEORY6,7 SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

HEALTH CARE SYSTEM/ORGANIZATION: 

 “Organisational: theories to explain 

change at a higher order social and 

systems” (Michie et al., 2005)

As applied at multiple levels; e.g., 

team, unit, facility, or VISN

1. Diffusion theory • Rogers E. Diffusion o

Schuster, Inc., 2004. 

• Dearing J. Improving t

by using diffusion theoCommunication 2004; 

2. Social networking • Valente TW. Social ne

diffusion of innovation

• www.istheory.yorku.c

3. Complexity and systems theory Burnes, B. (2005). Com

organizational change. Management Reviews

• Plsek P: Redesigning h

the science of complex the Quality Chasm: A Century. Washington DSciences; 2000:309-32

• Litaker D et al. Using 

Interventions that ImprPrimary Care. J Gen In

2:S30-4. 

6 Yano EM The role of organizational research in implementing evidence-based practice: QUERI Series Implement Sci 2008, 3:29 7 Klein, K.J. and J.S. Sorra, The Challenge of Innovation Implementation. Acad Mgmt Review, 1996. 21(4): p. 1055-1080. 
EIS Theory Team, Denver July 2010 

LEVELS OF THEORY SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

HEALTH CARE SYSTEM/ORGANIZATION (cont’d) 4. Receptive context • Pettigrew A, Ferlie E, 

Change--The Case of tMoney & Mgmt 1992, 

• Stetler C, et al. Institut

practice: an organizatistrategic change. Impl

5. Theory of the organizational determinants • Weiner BJ, et al. Using 

understand the determiimplementation of worprograms. Health Educ 

6. Organization change management 

• Gustafson DH, et al. D

to predict outcomes of Serv Res. 2003 Apr;38

• Molfenter et al. Prospe

model to predict organMgmt Rev 30(3), July/

• Krein SL, et al. Improv

diabetes: An example move from evidence to Series. Implement Sci. 

7. Organizational transformation 

• Lukas CV, et al. Trans

care systems: an organManage Rev. 2007 Oc

• Lukas CV, Engle RL, 

Seibert M, Petzel RA, Strengthening organizabased clinical practiceReview, in press. 
EIS Theory Team, Denver July 2010 

LEVELS OF THEORY SAMPLE IMPLEMENTATION-RELATED THEORIES RELEVANT/S

HEALTH CARE SYSTEM/ORGANIZATION (cont’d) 

8. PARIHS • Rycroft-Malone, J., et 

factors that influence t

into practice. J Clin Nu

• Helfrich C et al. Organ

assessment (ORCA): Dbased on the PromotinServices (PARIHS) fra

Jul 14;4:38. 

9. Group dynamics & Team learning 

• Group Dynamics: The

APA PsychNET (Jour

• Edmondson, A. (1999)

Learning Behavior in WScience Quarterly, 44(

• Nembhard, I., & Edmo

safe: the effects of leadprofessional status on improvement efforts in Organizational Behavi

10. TCU Program Change Model 

• Simpson DD: A conce

transferring research to 

2002, 22(4):171-182. 

• Roman PM, Johnson J

of new technologies in Subst Abuse Treat 200

• Simpson DD, Flynn PM

treatment: A stage-basJ Subst Abuse Treat. 22007 Apr 16. 
Additional Theories
PARIHS Framework

• Promoting Action on 

Research Implementation in Health Services (PARIHS)*

• SI = f (E,C,F)• Organizational 

High

Readiness for Change Assessment (ORCA) tool

Helfrich C, Li Y-F, Sharp N, Sales A: Organizational readiness to 

change assessment (ORCA): Development of an instrument based on the Promoting Action on Research in Health Services (PARiHS) framework. Implementation Science 2009, 4:38.

Estabrooks, C. A., J. E. Squires, et al. (2009). "Development and 

assessment of the Alberta Context Tool." BMC Health Serv Res 9(1): 234.

Low

Evidence

Context 

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

US HHS-National Institutes of Health (2005). Theory at a Glance: A guide for health promotion practice 2nd. Re

from http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf
Process Theory

Stetler CB. Updating the Stetler Model of research utilization to facilitate evidence-based practice. Nurs Outlook

Dec;49(6):272-9. 
Mixed Theory

The Practical, 

Robust 

Implementation 

and 

Sustainability 

Feldstein, A. C., & Glasgow, R. E. (2008). A practical, robust implementation and sustainability model (PRISM) for integratin

into practice. Jt Comm J Qual Patient Saf, 34(4), 228-243.

Sustainability 

Model

(PRISM)
MixedTheory

Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB. Interventions in organizational and community building evidence on dissemination and implementation in health services research. Adm. Policy Ment. Health 200

ASSESS MONITOR EVALUAT
Individual Level Change

Theory of Planned Behavior

Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179-211.http://people.umass.edu/aizen/tpb.diag.htm l
Individual Level Change

US HHS-National Institutes of Health (2005). Theory at a Glance: A guide for health promotion practice 2nd. Re

from http://www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf
Individual Level Change

Organizational 

Godin, G., Belanger-Gravel, A., Eccles, M., & Grimshaw, J. (2008). Healthcare professionals' intentions and beh

review of studies based on social cognitive theories. Implement Sci, 3(1), 36.
Healthcare System/Organization

Social Network Theory

http://www.istheory.yorku
Characteristics Com m unication 

Social Syste m Feedback on Use

of the EBPG

Intervention:

• Modify Policies, Procedure,  Standards• Modify Medical Record Forms• Senior Administrator Education and Support• Orientation of New Staff

Hospital; Patient Care Unit

 • Characteristics of

Translational Research Mo

Characteristics 

of the Innovation

 Intervention:• Education• Opinion leaders• Change champion• Core group• Outreach/academic detailing• Action plan

Com m unication

Proce ss

 Communication

Use rs

Feedback on Useof the EBPG

EBP Guideline on a

Specific Topic

 Intervention: • Nature of Topic• Credibility• Localization• Practice Prompts

Intervention:

• Performance Gap Assessment• Audit and Feedback• Focus Groups• Trying the EBPG• Conferencing

 • • • 

Nurses & Physicians

• Characteristics of

*Based on Rogers’ model of Diffusion 

of Innovation

Titler, M. G., & Everett, L. Q. (2001). Translating research into practice. Considerations for critical care investigators. Critical Care Nursing Clinics of North America, 13(4), 587-604. 
EIS- Intro Program Session 3: The Role and Selection of Theoretical 

Frameworks in Implementation Research

Thursday, June 7, 2012 2:00 PM - 3:00 PM EDT

Strong encouragement to read:

1. Damschroder, L., Aron, D., Keith, R., Kirsh, S., Alexander, J., & Lowery, J. (2009). Fostering 

implementation of health services research findings into practice: a consolidated framework 

for advancing implementation science. Implement Sci, 4(1), 50.

2. Klein, K. J., Conn, A. B., & Sorra, J. S. (2001). Implementing computerized technology: An 

organizational analysis. Journal of Applied Psychology, 86(5), 811-824.

3. French, S. D., Green, S. E., O'Connor, D. A., McKenzie, J. E., Francis, J. J., Michie, S., et al. 

(2012). Developing theory-informed behaviour change interventions to implement evidence 

into practice: a systematic approach using the Theoretical Domains Framework. Implement 

Sci, 7(1), 38. doi: 10.1186/1748-5908-7-38

Extra reading:

1. Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., et al. 

(2012). A compilation of strategies for implementing clinical innovations in health and 

mental health. Medical Care Research and Review, 69(2), 123-157. doi: 

10.1177/1077558711430690

2. Michie, S., Johnston, M., Francis, J., Hardeman, W., & Eccles, M. (2008). From Theory to 

Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change 

Techniques. Applied Psychology: An international review, 57(4), 660-680.