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      Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

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          Abstract

          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.

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          Most cited references84

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          ORGANIZATIONAL INNOVATION: A META-ANALYSIS OF EFFECTS OF DETERMINANTS AND MODERATORS.

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            Organizational Justice: Yesterday, Today, and Tomorrow

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              Evaluating the successful implementation of evidence into practice using the PARiHS framework: theoretical and practical challenges

              Background The PARiHS framework (Promoting Action on Research Implementation in Health Services) has proved to be a useful practical and conceptual heuristic for many researchers and practitioners in framing their research or knowledge translation endeavours. However, as a conceptual framework it still remains untested and therefore its contribution to the overall development and testing of theory in the field of implementation science is largely unquantified. Discussion This being the case, the paper provides an integrated summary of our conceptual and theoretical thinking so far and introduces a typology (derived from social policy analysis) used to distinguish between the terms conceptual framework, theory and model – important definitional and conceptual issues in trying to refine theoretical and methodological approaches to knowledge translation. Secondly, the paper describes the next phase of our work, in particular concentrating on the conceptual thinking and mapping that has led to the generation of the hypothesis that the PARiHS framework is best utilised as a two-stage process: as a preliminary (diagnostic and evaluative) measure of the elements and sub-elements of evidence (E) and context (C), and then using the aggregated data from these measures to determine the most appropriate facilitation method. The exact nature of the intervention is thus determined by the specific actors in the specific context at a specific time and place. In the process of refining this next phase of our work, we have had to consider the wider issues around the use of theories to inform and shape our research activity; the ongoing challenges of developing robust and sensitive measures; facilitation as an intervention for getting research into practice; and finally to note how the current debates around evidence into practice are adopting wider notions that fit innovations more generally. Summary The paper concludes by suggesting that the future direction of the work on the PARiHS framework is to develop a two-stage diagnostic and evaluative approach, where the intervention is shaped and moulded by the information gathered about the specific situation and from participating stakeholders. In order to expedite the generation of new evidence and testing of emerging theories, we suggest the formation of an international research implementation science collaborative that can systematically collect and analyse experiences of using and testing the PARiHS framework and similar conceptual and theoretical approaches. We also recommend further refinement of the definitions around conceptual framework, theory, and model, suggesting a wider discussion that embraces multiple epistemological and ontological perspectives.
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                Author and article information

                Journal
                Implement Sci
                Implementation Science : IS
                BioMed Central
                1748-5908
                2009
                7 August 2009
                : 4
                : 50
                Affiliations
                [1 ]HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System (11H), 2215 Fuller Rd, Ann Arbor, MI 48105, USA
                [2 ]VA HSR&D Center for Quality Improvement Research (14W), Louis Stokes Cleveland DVAMC, 10701 East Blvd, Cleveland, OH 44106, USA
                [3 ]Health Management and Policy, School of Public Health, University of Michigan,109 S. Observatory (M3507 SPH II), Ann Arbor, Michigan 48109-2029, USA
                Article
                1748-5908-4-50
                10.1186/1748-5908-4-50
                2736161
                19664226
                8a1aae80-ebcd-43fd-a7c9-1f5c976e3b55
                Copyright © 2009 Damschroder et al., licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 5 June 2008
                : 7 August 2009
                Categories
                Research Article

                Medicine
                Medicine

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