Implementation Research Theoretical Frameworks CyberSeminar Series

1. Implementation Research Theoretical FrameworksCyberSeminar Series 4-Part Series: April 7 April 14 May 5 May 12 CIPRS: Stetler/Damschroder, Theoretical Frameworks

2. Objectives • Purpose/potential value and uses • Process for selection and use • Nature and underlying rationale of specific frameworks/approaches • Evaluation CIPRS: Stetler & Damschroder Theoretical Frameworks

3. APRIL • April 7: Foundations Cheryl Stetler & Laura Damschroder • April 14: Applying a Framework Phil Ullrich A Mixed-model Approach-Intro Jeffrey Smith CIPRS: Stetler & Damschroder Theoretical Frameworks

4. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

5. 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 12th session Send as early as possible to: cheryl.stetler@comcast.net CIPRS: Stetler & Damschroder Theoretical Frameworks

6. Foundations • What are implementation “theories”? • How and why are they useful? CIPRS: Stetler & Damschroder Theoretical Frameworks

7. Foundations Terminology • Theory • Theoretical/conceptual framework • Model CIPRS: Stetler & Damschroder Theoretical Frameworks

8. 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) CIPRS: Stetler & Damschroder Theoretical Frameworks

9. 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” CIPRS: Stetler & Damschroder Theoretical Frameworks

10. 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) CIPRS: Stetler & Damschroder Theoretical Frameworks

11. 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) CIPRS: Stetler & Damschroder Theoretical Frameworks

12. No Commonality… Illustration1! • Conceptual models • Theories of change • Frameworks CIPRS: Stetler & Damschroder Theoretical Frameworks 1.Ref: Graham& Tetroe, in press

13. Why “Theory”? Theories, models, frameworks provide a systematic method: … for identifying, understanding, operationalizing & evaluating the black box phenomenon = “IMPLEMENTATION” CIPRS: Stetler & Damschroder Theoretical Frameworks

14. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks 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.

15. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

16. QUERI Dual Objectives • Replicate successful implementation • Help navigate complexity of implementation & sustainability • Tailor essential factors to fit the context CIPRS: Stetler & Damschroder Theoretical Frameworks

17. Using Theory for Implementation Planning Select interventionsthat fit with plannedstrategies (based on theory) Select theory of planned behaviorchange Identify potential strategies for achieving change Assess fit with initial theory Evaluate effectivenessof intervention,strategies, tools Launch interventionusing identified toolsand strategies Identify interventiontools that fit bothstrategy and theory CIPRS: Stetler & Damschroder Theoretical Frameworks See references: Sales et al., 2006

18. Using Theory for Implementation Planning Select interventionsthat fit with plannedstrategies (based on theory) Select theory of planned behaviorchange Identify potential strategies for achieving change Frameworks Theories Models Assess fit with initial theory Select theory of planned behaviorchange Evaluate effectivenessof intervention,strategies, tools Launch interventionusing identified toolsand strategies Identify interventiontools that fit bothstrategy and theory CIPRS: Stetler & Damschroder Theoretical Frameworks See references: Sales et al., 2006

19. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

20. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks 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.

21. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

22. 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. CIPRS: Stetler & Damschroder Theoretical Frameworks

23. Ottawa Model ofResearch Use • Action-oriented • Prescribes 3 main steps • Assess • Monitor • Evaluate CIPRS: Stetler & Damschroder Theoretical Frameworks Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can. J. Nurs. Res. 2004;36(2):89-103.

24. Framework of Dissemination in Health Services Intervention Research CIPRS: Stetler & Damschroder Theoretical Frameworks Mendel et al, 2008

25. 2001 CIPRS: Stetler & Damschroder Theoretical Frameworks

26. Impact Theories - 1 • Individual-level theories • Stage of change • Cognitive • Educational • Motivational CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007

27. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007

28. Social Cognitive Theory • 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. Organizational Setting CIPRS: Stetler & Damschroder Theoretical Frameworks http://www.cw.utwente.nl/theorieenoverzicht/Theory%20clusters/Health%20Communication/Social_cognitive_theory.doc/

29. Theory of Planned Behavior • Motivational theory CIPRS: Stetler & Damschroder Theoretical Frameworks 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

30. Impact Theories - 2 • Social context theories • Social Marketing • Social learning • Communication • Social network & influence • Teamwork • Professional development • Leadership CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007.

31. Social Network Theory • Tailor engagement strategy to social networks CIPRS: Stetler & Damschroder Theoretical Frameworks http://www.istheory.yorku.ca/socialnetworktheory.htm

32. Impact Theories - 3 • Organizational Context Theories • Innovative organizations • Quality management • Integrated care • Complexity • Organizational learning • Organizational culture • Political & Economic Context Theories • Reimbursement • Contracting CIPRS: Stetler & Damschroder Theoretical Frameworks Grol et al, 2007.

33. Roger’s Theory of Diffusion Characteristics of the intervention Effective implementation Organizational characteristics Outcomes Adoption decision Environmental context 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. CIPRS: Stetler & Damschroder Theoretical Frameworks

34. Greenhalgh, et al’s Conceptual Model CIPRS: Stetler & Damschroder Theoretical Frameworks

35. High Evidence High Facilitation Low Context High PARiHS Framework Positive influence • 3 major domains • Evidence • Context • Facilitation • Continuums of high and low values that interrelate to influence implementation Negative influence Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual. Health Care 1998;7(3):149-58. CIPRS: Stetler & Damschroder Theoretical Frameworks

36. PRISM: Practical, Robust Implementation and Sustainability Model • 4 Domains: • Intervention Design • Recipients • External Environment • Implementation & Sustainability Infrastructure CIPRS: Stetler & Damschroder Theoretical Frameworks See references: Feldstein & Glasgow, 2008

37. Implementation Effectiveness Model • Quantitative measures of predictors of implementation effectiveness • Strength of relationships empirically estimated CIPRS: Stetler & Damschroder Theoretical Frameworks Klein KJ, Conn AB, Sorra JS. Implementing computerized technology: An organizational analysis. J Appl Psychol. 2001;86(5):811-824.

38. CFIRConsolidated 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 CIPRS: Stetler & Damschroder Theoretical Frameworks See references: Damschroder et al. Under Review.

39. Dual QUERI Objectives: Revisited • Generalize knowledge about how to implement and sustain interventions • Replicate successful implementation CIPRS: Stetler & Damschroder Theoretical Frameworks

40. Selecting & Using a Theoretical Framework CIPRS: Stetler/Damschroder, Theoretical Frameworks

41. 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 Uses/Potential Value [PDI*] CIPRS: Stetler & Damschroder Theoretical Frameworks

42. 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] CIPRS: Stetler & Damschroder Theoretical Frameworks

43. 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] “Theoretical” Selection CIPRS: Stetler & Damschroder Theoretical Frameworks

44. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks

45. 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? CIPRS: Stetler & Damschroder Theoretical Frameworks

46. 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? CIPRS: Stetler & Damschroder Theoretical Frameworks

47. 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 usefulnessfor your issue • Assess “fit” of these various frameworks and make selection/s of one or more, as appropriate CIPRS: Stetler & Damschroder Theoretical Frameworks

48. 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?) CIPRS: Stetler & Damschroder Theoretical Frameworks

49. 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. CIPRS: Stetler & Damschroder Theoretical Frameworks

50. 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 CIPRS: Stetler & Damschroder Theoretical Frameworks