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Consolidated Framework for Implementation Research

Watch the following video from Walter Zingg, who is discussing CFIR frameworks and how they can be used in Implementation Research.
Hello. My name is Walter Zingg and I work at the University of Geneva Hospitals. And today, I will talk about the consolidated framework for implementation research. What is CFIR? For me, CFIR is a roadmap on implementation for non-social scientists, such as myself. I’m a medical doctor, and I do not know about the different theories in implementation research. This is where CFIR did the job for me. CFIR was a systematic review on the different theories in implementation research, and it is a meta-theory mapping theories to five domains. What are the five domains? Let’s start with the inner setting, or in the medical field, we can say this is the hospital.
Within the inner setting are the individuals, everybody who works in the hospital. There is the outer setting, everything around the hospital, and then there is the intervention, maybe not adapted yet to the context, in an earlier stage. And adapted to the context, this is what you want to implement. This is your project. And then there is the implementation process. Let’s start with the inner setting. The inner setting has structural characteristics shaping the social architecture. This is the clustering of people within differentiated groups and the coordination of those groups. There are structural determinants, such as size, functional differentiation, slack resources, and specialisation.
We can say that size and age of an organisation are both negatively associated with implementation when beauracratic structure is increased as a result. There is communication and networks. Intra-organisational communication networks, internal boundary spanning, and organisational structure fall into this. We can say that clear role models, teamwork, power and authority structures influence implementation. And then there is the organisational culture, which refers to norms, values, and basic assumptions of a given organisation. It’s not easy to say what is the organisational culture where you work, for instance. So it is easiest to say, our organisational culture is just the way we work around here. We can say that culture is relatively stable. It is socially constructed and subconscious.
The implementation climate has different elements, tension for change, degree to which stakeholders perceive the current situation as intolerable, relative priority, the perception that an intervention or a project is a key organisational priority, incentives like goal sharing awards, promotions, raises in salary. Less tangible incentives also fall into this category such as increased stature or respect. There is leadership engagement, which is the commitment, involvement and accountability from leaders or managers. But we can say that anything less than wholehearted support from leaders dooms implementation to failure. There are resources, important the level of resources dedicated for implementation, but also for ongoing operations, including money, training, education, physical space and time.
Let’s move to individuals, and please take time to read what you see on the slide. So health care workers are no potato bags. They are individuals, human beings, and whatever you confront them with, there is a reaction. And you have to react to this reaction, and you have to make this in favour for you. The performance of every organisation surely depends on various influences, such as society, the culture, the economy, legal frameworks, health care systems. But at the heart of it, it depends on individuals in your organisation. It is the individuals shaping the organisation, and those individuals, they are different. They have different knowledge. They are young. They get more knowledge during the years. They have their beliefs.
They have, or may not have, issues with self efficacy. They are always in a state of change. They learn during their work experiences, in all the years they work in the organisation. You have to take that into account, and the more experience, you can give responsibility within your project. They have an attitude towards your organisation. If it’s positive, probably it’s a facilitator for your project. If it’s negative, it may be a barrier for the implementation of your project. What is the outer setting? Outer setting are external strategies to spread interventions, including policies, regulations, could be governmental or other central entities, external mandates, recommendations and guidelines, sometimes from societies, not necessarily from political levels.
Pay-for performance structures, collaboratives, and public or benchmark reporting. We can say that political directives increase motivation, though not capacity for organisations to implement, which is an issue specifically in the long term sustainability of a project. Adverse effects of public reporting, such as cover up, gaming, box checking rather than true commitment, have been described and are a true issue with that. There is peer pressure. And now I do not talk about the peer pressure within your organisation, but with different other organisations. It means the mimetic or competitive pressure to implement an intervention, typically because most or other peers or competing organisations have already implemented what you are going to implement.
We can also say that in highly competitive markets, organisations may more likely implement new interventions. Let’s move to the intervention. There is the source of the intervention and how it is perceived by key stakeholders. Usually, grassroots approaches are more favourable than top-down and imposed procedures or interventions. The evidence, strength and quality. This is the perceived strength of evidence. We can say that the more sources of evidence are used, the more likely innovations or projects will be taken up. The relative advantage, the stakeholders’ perception of the advantage of implementing the intervention versus the organisational status quo. And here, we have to say that strong scientific evidence is not a guarantee for perceived relative advantage.
The relative advantage is really tested on the ground and in daily practise. The adaptability is really important. When you think about your project, your project or your intervention has certainly a core component, the non-negotiable part of it, something that really needs to be implemented. And then there is an adaptive periphery which takes into account the context of your organisation. You cannot force a project or an intervention into an organisation, or hammer it into an organisation, if there is not a minimum level of adaptability to the organisation. A next element is complexity. Again, it is perceived by the peers, difficulty or complexity of the intervention.
We can say that technical interventions are more tangible than behavioural interventions and thus are probably easier to implement. And behavioural interventions need much more skills and probably also a more multimodal and multi-professional approach to be successful. We also can say on the other hand, complex behavioural change interventions can work in favour for an implementation. So if organisations embrace an intervention as a fundamental change to processes upfront, it may be even positive to implement your project. Finally, let’s move to the implementation process. The implementation process oscillates something between let it happen and make it happen. So let it happen, a natural emergent process that things are just taking place without you interfering with it.
And make it happen, to the most extreme in the military service, where you just say, you do this and then it’s just done. In real life, we are something in between. And usually when we start to implement that project, we have to help it happen. There are different aspects to the project’s implementation. It is planning. Planning is the most important in the implementation process, and it takes time, and it’s worth taking the time. It is engaging. You need to have the right people in the right seats. The member of the starting steering group must be carefully selected and doing their job. Involving all stakeholders early in the implementation.
Do not wait until you want to start your implementation, but they should be part of the process and the planning process of your project before you start implementing. Personal characteristics matter, but relationships between individuals can be more important than individual roles or characteristics, especially when it comes to having this specific person in your group because this person is influential, or even worse, has a formal position in the organisation. And then there is the executing part, where you can help implementation by dry runs and simulations, doing pilots, and certainly breaking down complex interventions to manageable parts.
For instance, you do an intervention part by part, you start with one part of your project, and then move to the next part of your project. And this also makes it much more interesting for your peers in your organisation. And finally, evaluating. This is the quantitative but also qualitative reflection about the progress and the quality of implementation accompanied with regular personal and team debriefings about progress and experience. Basically, it is the Act, Plan, Do, Study circle, the PDSA circle. You have to apply several times repeatedly over your implementation process. This was CFIR, and I hope I could help you to have an understanding. I would encourage you to go into the original paper. It is quite well described.
It is a bit more complex than what you just heard now. Of course it is. But it will help you to understand more about implementation and how you can succeed better by implementing your project in your institution. Thank you very much.

In this video, Dr Walter Zingg discusses CFIR frameworks and how they can be used in implementation frameworks.

The CFIR provides a systematic review on different theories of implementation, which are split into five domains. You can find more information here.

The video talks you through the implementation climate, the intervention itself and it’s instillation.

Remember that the aim is adapted implementation. It must fit the setting it is being put in. Medical staff are all individual people with their own attitudes towards the organisation, knowledge and experience, and they are in a constant state of change. This should be taken into consideration as it may affect the implementation.

Please find a pdf of the PowerPoint slides in the downloads section below.

In the comments below please let us know:

  • What do you think is the most important factor to consider when implementing a program into a healthcare setting?
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