This document summarizes a webinar presentation on the Consolidated Framework for Implementation Research (CFIR). The presentation was given by Laura Damschroder on November 12, 2015 through the National Centre for Methods and Tools. It provided an overview of the CFIR, including its five domains and 39 constructs. It then presented a case study applying the CFIR to analyze implementation of the VA MOVE! weight management program across several sites. Qualitative and quantitative data were collected and coded using the CFIR framework. Differences in implementation effectiveness across sites were explored in relation to ratings of CFIR constructs. The presentation concluded by discussing how findings can be built upon and compared across multiple studies to develop knowledge about implementation.

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Funded by the Public Health Agency of Canada | Affiliated with McMaster University
Production of this presentation has been made possible through a financial contribution from the Public Health Agency of Canada. The
views expressed here do not necessarily reflect the views of the Public Health Agency of Canada..
The Consolidated Framework for
Implementation Research (CFIR):
Application and Tools
Presenter:
Laura J. Damschroder, MS, MPH
November 12, 2015
1:00 – 2:30 PM ET

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The Consolidated Framework for
Implementation Research (CFIR):
Application and Tools
http://www.nccmt.ca/registry/view/eng/210.html
Episode 20
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National Collaborating Centre for
Methods and Tools
• dedicated to improving access to, and use of,
methods and tools that support moving
research evidence into decisions related to
public health practice, programs, and policy in
Canada.
7

8. Poll Question #2
What sector are you from?
1. Public Health Practitioner
2. Health Practitioner (Other)
3. Education
4. Research
5. Provincial/Territorial/Government/Ministry
6. Municipality
7. Policy Analyst (NGO, etc.)
8. Other
8

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Laura J. Damschroder, MS, MPH
Research Scientist
Ann Arbor Veteran’s Affairs,
Center for Clinical Management
Research and HSR&D Center of
Excellence
Presenter
9

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11. The Consolidated Framework for Implementation
Research (CFIR): Application and Tools
Laura J. Damschroder, MS, MPH
November 12, 2015
National Centre for Methods and
Tools (NCCMT) Webinar Series
McMaster University
The views expressed in this presentation are my
own and do not reflect the position or policy of
the Department of Veterans Affairs or the
United States government

12. Poll Question #3
Have you heard of the CFIR?
A. What is the CFIR?
B. I am familiar with the CFIR
C. I have thought about using the CFIR in my work
D. None of the above
12

13. Goals for Implementation Research
Case study: Application of the CFIR
Building the knowledge-base
Implementation Strategies
Outline
Roadmap for implementation science

14. • Science
– Collaborative, systematic knowledge
building
• Praxis
– Tools and processes for practitioners
– Identify effective strategies
• Tailored to context
– Contribute to culture of learning
healthcare system
Dual Goals for Implementation
ResearchIS Goals

15. Power of Theory
• Organizing framework for research studies
• Build scientific knowledge base
• Context, mechanisms of action
• Generalize through theory
• Syntheses
• Provides common terms & definitions
• Efficient way to systematically build collective
knowledge
Colquhoun, H., Leeman, J., Michie, S., Lokker, C., Bragge, P., Hempel, S., … Grimshaw, J. (2014). Towards a
common terminology: a simplified framework of interventions to promote and integrate evidence into health
practices, systems, and policies. Implementation Science, 9, 51.
Foy R, Ovretveit J, Shekelle PG, et al. The role of theory in research to develop and evaluate the
implementation of patient safety practices. Quality & safety in health care. Feb 11 2011.
IS Goals

16. Poll Question #4
Which of the following best describes
your work?
A. Developing and testing innovations
B. Developing and testing implementation
approaches
C. Implement innovations
D. All of the above
E. Other
16

17. Innovations to Improve Patient Care
17
• “Active Ingredients”
• Adaptability
Innovation Science Goal:
Improved health & well being of patients
Colquhoun, H., Leeman, J., Michie, S., Lokker, C., Bragge, P., Hempel, S., … Grimshaw, J. (2014). Towards a common terminology: a simplified
framework of interventions to promote and integrate evidence into health practices, systems, and policies. Implementation Science, 9, 51.
Establishing “internal
validity” is priority
Control or ignore
CONTEXT

18. Weight Loss Program Innovation
• ASPIRE Comparative Effectiveness Trial
– High fidelity coaching  more weight loss
• VA DPP Comparative Effectiveness Trial
– DPP higher fidelity to ASPIRE-ID’d domains of
coaching
• Affirmed by patient ratings of delivery
– National MOVE! program guidance updated
• http://www.move.va.gov/GrpSessions.asp
18

19. Innovations to Improve Patient Care
19
• “Active Ingredients”
• Adaptability
Innovation:
Improved health & well being of patients
RCTs along do not provide
sufficient information

20. Preparing for and Explaining Implementation
20
• Barriers & Facilitators
• Why did/will it work?
Implementation Science Goal:
Drawing on knowledge about how an innovation will achieve expected benefits and the
causes, effects, and factors that determine its success (or failure) in clinical practice
Grol, et al. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Quarterly, 85(1), 93–138.
Establishing “external
validity” is priority
Embrace and
understand CONTEXT
…in all its wicked
complexity

21. Use of theory in implementation
Assess targeted
Innovation and
Context
Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into
health care practice. J. Gen. Intern. Med. Feb 2006;21 Suppl 2:S43-49.
Bartholomew, L. K., Parcel, G. S., & Kok, G. (1998). Intervention mapping: a process for developing theory- and evidence-
based health education programs. Health Educ Behav, 25(5), 545-563.
Use theory to
guide assessment

22. Case Study
VA MOVE! Weight Management
Program
22
CFIR

23. Highly Variable Implementation
MOVE!®
23
Number of Visits Reported by Study Site 1 & 2 Years Since Dissemination
0
10
20
30
40
50
60
70
FY 2007 FY 2008
#Visits/1000Veterans
CFIR

24. Outcomes
24Proctor, E., H. Silmere, R. Raghavan, P. Hovmand, G. Aarons, A. Bunger, R. Griffey, and M. Hensley, Outcomes for implementation research:
conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health, 2011. 38(2): p. 65-76.

25. Assess targeted
EBP change and
context
French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement
evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24
2012;7(1):38.
Who needs to do what
differently?
Which barriers &
facilitators need to be
addressed?
Applying Theory

26. Consolidated Framework for
Implementation Research (CFIR)
• A comprehensive framework to
promote consistent use of constructs,
terminology, and definitions
– Five Domains
– 39 Constructs
26
Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J: Fostering implementation of
health services research findings into practice: a consolidated framework for advancing
implementation science. 2009, 4:50.
CFIR

27. OUTER CONTEXT
INNER CONTEXT
PRACTITIONER
INNOVATION
PROCESS
SLIDE CREDIT: ©Dr. Melanie Barwick, SickKids / U Toronto, Canada 2015
Consolidated Framework for Implementation Research
LOCAL REALITY
CFIR

28. CFIR
Consolidated Framework for
Implementation Research
Damschroder L, Aron D, Keith R, Kirsh S, Alexander J, Lowery J: Fostering implementation of health services research findings into practice: a consolidated
framework for advancing implementation science. 2009, 4:50.

29. Poll Question #4
What types of data do you typically rely
on in your work?
A. Qualitative data e.g., interview transcripts,
field notes
B. Quantitative data e.g., surveys
C. A lot of both
D. Neither
29

30. Understanding Context
• Qualitative Data
– Interviews
– Artifact data (e.g., P&Ps, journals, meeting notes)
– Quantitative ratings
30

31. 31
www.CFIRGuide.org

32. 32

33. 33

34. 34

35. 35

36. Understanding Context
• Qualitative Data
– Interviews
– Artifact data (e.g., P&Ps, journals, meeting notes)
– Quantitative ratings
• Quantitative Measures
– Not well developed
• Martinez, R., C. Lewis, and B. Weiner, Instrumentation issues in implementation science. Implementation Science, 2014.
9(1): p. 118
– Synthesis of measures
– Chaudoir, S.R., A.G. Dugan, and C.H. Barr, Measuring factors affecting implementation of health innovations: A systematic review
of structural, organizational, provider, patient, and innovation level measures. Implement Sci, 2013. 8(1): p. 22.
– Assessment of measures – work in progress
– REGISTRATION IS FREE BUT NECESSARY:
http://www.societyforimplementationresearchcollaboration.org/sirc-projects/sirc-instrument-
project/measures-collection/
– Lewis, C., C. Stanick, R. Martinez, B. Weiner, M. Kim, M. Barwick, and K. Comtois, The Society for Implementation Research
Collaboration Instrument Review Project: A methodology to promote rigorous evaluation. Implementation Science, 2015. 10(1):
p. 2.
36

37. Quantitative Measures
http://cfirguide.org/quant.html
CFIR
7th Annual D&I
Conference
December 2014

38. Inner Setting: Networks &
Communications
• HIGH IMPLEMENTATION SITES:
– Both sites had a high degree of “teamness”
– Meet regularly
• LOW IMPLEMENTATION SITES
– Did not have regular team meetings
– Lack of effective communication
• Patients confused about the program
Damschroder, L.J. and J.C. Lowery, Evaluation of a large-scale weight management program using the consolidated framework for
implementation research (CFIR). Implement Sci, 2013. 8: p. 51.
CFIR

39. Data Collection, Coding, Rating
• Coded qualitative data using CFIR as
“codebook”
• Rated strength and valence of each construct
– Scale: -2 to +2
– By transcript
– Rolled up ratings by sites
• Blinded to site outcomes
CFIR

40. Qualitative Data: Construct Ratings
40
Implementation Effectiveness: Low High
I. INTERVENTION CHARACTERISTICS
Relative advantage -2 1 2 2
II. OUTER SETTING
Patient needs & resources -2 0 2 2
External Policy & Incentives -1 -2 0 1
III. INNER SETTING
Networks and communications -2 -2 2 2
Implementation Climate
Tension for change 0 0 1 1
Relative priority -1 -2 1 2
Goals and feedback -2 -1 1 2
Learning climate N/A -1 1 2
Readiness for Implementation
Leadership Engagement -2 -1 2 2
Available resources -2 -2 1 -1
V. PROCESS
Planning -1 N/A 1 1
Executing -2 1 2 2
Reflecting & Evaluating -1 -2 1 2
CFIR
Goals and feedback

41. Number of Referrals per 1000 Veterans by Site
Variable referral rates
Follow-up Interviews
CFIR

42. Site ID V03-3 V02-6 V03-4 V05-1 V01-2 V03-1 V01-4 V
Referral Rate 2.0094 2.3236 2.5855 5.9953 6.0434 6.8834 7.7227 1
Structural
Characteristics
-2 -2 -2 -1 0 -1 -1
Networks &
Communications
-1 1 . . . -1 -1
Compatibility 1 -1 1 1 -1 1 -1
Referral rate & Construct
Ratings by SiteCFIR

43. Compatibility
• Correlation: 0.55 (p=0.08)
0
5
10
15
V03-3 V02-6 V03-4 V05-1 V01-2 V03-1 V01-4 V01-3 V02-2 V01-6 V02-3
Referred/1000
-2
-1
0
1
2
CFIR

44. Compatibility
• Negative Rating – e.g.,
– Only providers could refer to TLC in some sites
• Our nurses are specifically forbidden to write orders
…everything that gets written has to be written by a
physician[…] this has formed a really labor intensive
situation for practitioners, so they are super
rebelling against anything else coming down. [MOVE!
Coordinator, V02-6]
CFIR

45. Compatibility
• Positive rating – e.g.,
– Perceived compatibility with clinical initiatives
• …this …really helps the patient to have ownership
for their processes and their living, and it definitely
blends very nicely with the health coaching
CFIR

46. BUILDING ON FINDINGS ACROSS
STUDIES
Knowledge

47. Comparing Findings Across Studies
47
Study: MOVE! TeleMOVE TLC
Structural Characteristics
Networks & Communications
Tension for Change
Compatibility
Relative Priority
Goals & Feedback
Learning Climate
Leadership Engagement
Available Resources
Strongly Distinguishes
Weakly Distinguishes
Not assessed

48. Knowledge

49. Causal complexity:
Set Relations vs. Correlations:
• Equifinality: Various (combinations of) conditions can lead
to the same outcome.
• Conjunctural causation: Conditions do not necessarily
exert their impact on the outcome in isolation from one
another, but sometimes have to be combined in order to
reveal causal patterns.
• Asymmetrical causation: The occurrence and non-
occurrence of social phenomena require separate analysis
– the presence versus absence of conditions might play crucially
different roles in bringing about the outcome.
49
Knowledge

50. Qualitative Comparative Analysis
• Case-oriented analysis
– Rather than variable-oriented
• Based on set theory and Boolean algebra
• Appropriate when
– The phenomenon of interest is best understood in
terms of set relations
– Evaluate configurations of conditions across cases
• Describe causal complexity related to an outcome
• Number of cases does not matter
50
Knowledge

51. Use QCA to Reveal Combinations of
CFIR Constructs  Success
Studies Cases
7 53
• Behavioral Change Programs
– Group-based weight management
– Phone-based coaching for lifestyle change
– Technology-enabled weight management program
• TeleRetinopathy Program
• Specialty Care
– SCAN-ECHO
– Specialty Care Neighborhood
– E-Consults

52. What We Learned
• Causal complexity confirmed
• Different pathways lead to success
• Analytical limitations
– Solutions sets depended on the cases included
– Must KNOW your data – link with qualitative data
• A priori theories
• Triangulate through different analyses, theories
Knowledge

53. Preparing for and Explaining Implementation
53
• Barriers & Facilitators
• Why did/will it work?
Implementation:
Theories about how an innovation will achieve expected benefits and the causes, effects, and
factors that determine its success (or failure)
Grol, et al. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Quarterly, 85(1), 93–138.
Insufficient reporting of
contextual factors

54. Assess targeted
EBP change and
context
French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement
evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24
2012;7(1):38.
Develop tailored
implementation
strategy
Who needs to do what
differently?
Which barriers &
facilitators need to be
addressed?
What strategies could be
used to address barriers &
facilitators?
Applying Theory

55. Implementation Strategy
Construct Issue/Barrier Change Strategies
Goals &
Feedback
55
Powell, Byron J., Thomas J. Waltz, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica M. Matthieu,
Enola K. Proctor, and JoAnn E. Kirchner. "A refined compilation of implementation strategies: results from the Expert
Recommendations for Implementing Change (ERIC) project." Implementation Science 10, no. 1 (2015): 21.
•It is challenging to track
patients’ weight and
other measures over
time. Often staff lack
time and ability to
analyze these data and
develop cogent business
cases needed to support
the program.
• Clearly align program
data with org goals &
communicate CFIR
• Develop tools for quality
monitoring1
• Audit and provide
feedback1
• Anecdotal success
stories help to bring data
“alive” for leaders and
other stakeholders.
Strategies

56. Expert Recommendations for
Implementing Change (ERIC)
• A mixed methods approach to establish expert
consensus on a common nomenclature for
implementation strategy terms and definitions
Strategies

57. Engage
consumers
Train and
educate
stakeholders
Change
infrastructure
Develop stakeholder
interrelationships
Provide
interactive
assistance
Utilize financial
strategies
Use evaluative and
iterative strategies
Adapt &
tailor to
context
Support
clinicians
73 strategies clustered into 9 groups
1
2
3
28
3442 49
66&70
9
10
11
12
13
22
44
4
5
14
18
23
61
26
27
46
56
37
39
41
50
62
69
6
7
17
40
47
52
64
48
51
63
67
68
24
25
36 38
45
65
72
35
57
8
33
53
54
58
21
30
32
59
15
1629
60
19
20
31
43
55
71
73
SLIDE CREDIT: Dr. Byron Powell, University North Carolina, USA. 2015
Strategies

58. E.g., Provide Interactive Assistance
1
2
3
28
3442 49
66&70
9
10
11
12
13
22
44
4
5
14
18
23
61
26
27
46
56
37
39
41
50
62
69
6
7
17
40
47
52
64
48
51
63
67
68
24
25
36 38
45
65
72
35
57
8
33
53
54
58
21
30
32
59
15
1629
60
19
20
31
43
55
71
73
8 Centralize technical assistance 53 Provide local clinical supervision
33 Facilitation 54 Provide local technical assistance
SLIDE CREDIT: Dr. Byron Powell, University North Carolina, USA. 2015
Strategies

59. Tailoring to Context
• Which strategies best address specific
barriers as aligned with constructs from the
CFIR?
ERIC Strategies
• Build a coalition
• Identify and prepare champions
• Involve patients and family members
• Inform local opinion leaders
• Conduct educational meetings
• Use mass media
• Visit other sites
• Conduct educational meetings
• Conduct local consensus discussions
• Conduct educational outreach visits
• Capture and share local knowledge
• Tailor strategies
• Conduct local needs assessment
• Alter incentive/allowance structures
• Conduct cyclical small tests of change
• Develop a formal implementation blueprint
• Identify early adopters
• Promote adaptability
CFIR Constructs
I. INTERVENTION
CHARACTERISTICS
A Intervention Source
B Evidence Strength & Quality
C Relative advantage
D Adaptability
E Trialability
F Complexity
G Design Quality and Packaging
H Cost
II. OUTER SETTING
A Patient Needs & Resources
B Cosmopolitanism
C Peer Pressure
D External Policy & Incentives
III. INNER SETTING
A Structural Characteristics
B Networks & Communications
Strategies

60. Survey of Implementation Experts
Audit and provide feedback
Select and rank up to 7 strategies that best address barriers
related to Goals and Feedback:
♦ Goals are not clearly communicated or acted upon, nor do
stakeholders receive feedback that is
aligned with goals. ♦
Strategies

61. www.CFIRguide.org
Strategies

62. Tailor an Intervention Strategy
Select a
domain

63. Tailor an Intervention Strategy
Techniques
Select a construct
Learn more about
the construct in
the wiki, or click
Techniques

64. Tailor an Intervention Strategy
Audit and provide feedback
Obtain and use patient/consumer and family feedback
Facilitate relay of clinical data to providers
Process: Reflecting & Evaluating
Select techniques you
want to include for each
construct…

65. Tailor an Intervention Strategy
Repeat steps until all
relevant constructs have
been addressed, then
click “Create Tailored
Implementation Strategy”
Create Tailored
Implementation Strategy
0

66. Tailor an Intervention Strategy
Reflecting & Evaluating
• Facilitate relay of clinical data to providers
Structural Characteristics
• Create new clinical teams
• Make billing easier
• Change service sites
Leadership Engagement
• Provide clinical supervision
Evidence Strength & Quality
• Provide on-going consultation
Process
Inner Setting
The tool will generate a document
that lists the techniques you chose
which can then be used as a basis for
a documented tailored
Implementation Strategy
Innovation Characteristics

67. Assess targeted
EBP change and
context
French SD, Green SE, O'Connor DA, et al. Developing theory-informed behaviour change interventions to implement
evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. Apr 24
2012;7(1):38.
Develop tailored
implementation
strategy
Who needs to do what
differently?
Which barriers & facilitators
need to be addressed?
What techniques could be
used to address barriers &
facilitators?
How can change (progress) be
measured and understood?
Applying Theory

68. Applying Theory
68
Execute tailored
implementation
strategy
Assess targeted
EBP change and
context
Develop tailored
implementation
strategy
Concurrent
monitoring and
refinement
Theory-informed

69. Applying Theory
69
Execute tailored
implementation
strategy
Assess targeted
EBP change and
context
Develop tailored
implementation
strategy
Evaluate effectiveness
of implementation
strategy
Proctor E., et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm. Policy Ment
Health 2011;38:65-76

70. Achieving Optimal Outcomes
70
Clinical
Innovation
Adapted from: Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2009). Implementation research in
mental health services: An emerging science with conceptual, methodological, and training challenges. Administration and Policy in
Mental Health and Mental Health Services Research, 36(1), 24-34.
Roadmap

71. Applying Theory
7171
Assess fit of
findings with
initial theory
Execute tailored
implementation
strategy
Evaluate effectiveness
of implementation
strategy
Assess targeted
EBP change and
context
Develop tailored
implementation
strategy

72. Applying Theory
72
Assess fit of
findings with
initial theory
Execute tailored
implementation
strategy
Evaluate effectiveness
of implementation
strategy
Assess targeted
EBP change and
context
Develop tailored
implementation
strategy
Add to the
knowledge-base

73. Example Critique of CFIR

74. Roadmap for Implementation
Science
• Foundation: Common Terminology & Constructs
• Assess Context
– Quantitative & Qualitative
• Targeted innovations
– Intervention mapping (http://www.interventionmapping.com)
– Adaptations (http://www.biomedcentral.com/content/pdf/1748-5908-8-65.pdf )
• Implementation Strategies
– Strategy Taxonomy (e.g., http://www.implementationscience.com/content/10/1/21/abstract)
– Tailored to context (forthcoming)
• Generate Testable Theories
Roadmap

75. Packaging for the (real) world
• Guidance for planning successful implementations
– Context assessment tools
• Implementation Strategies
– “How to” execute strategies
– Tailored to context
• “Learning” repositories
– Collective learning
Roadmap

76. 76
What works where and why?
Contact:
Laura.Damschroder@va.gov

77. Poll Question #5
What are your next steps? I plan to …
A. access the CFIR Tool.
B. read the NCCMT summary of the CFIR
Tool.
C. consider using the CFIR Tool.
D. tell a colleague about the CFIR Tool.
77

78. Follow us @nccmt Suivez-nous @ccnmo
• Use Q&A to post comments
and/or questions
• ‘Send’ questions to All (not
privately to ‘Host’)
Q&A
Participant Side
Panel in WebExYour Comments/Questions
78

79. Your Feedback is Important
Please take a few minutes to share your thoughts
on today’s webinar.
Your comments and suggestions help to improve
the resources we offer and plan future webinars.
The short survey is available at:
https://nccmt.co1.qualtrics.com/SE/?SID=SV_8H
AZ4HrWTZsPszP
79

80. After Today
The PowerPoint presentation (in English and French)
and English audio recording will be made available.
These resources are available at:
PowerPoint: http://www.slideshare.net/NCCMT/
Audio Recording:
https://www.youtube.com/user/nccmt/videos
80

81. Join us for our next webinar
NCCMT’s Applicability & Transferability Tool
December 9, 2015 from 1:00 – 2:30pm EST
The Applicability and Transferability of Evidence
Tool (A&T Tool) is designed to help public health
managers and planners decide whether the
evidence you find can be used in your local setting.
Register at: https://health-evidence.webex.com
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Funded by the Public Health Agency of Canada | Affiliated with McMaster University
The views expressed here do not necessarily reflect the views of the Public Health Agency of Canada.
For more information about the
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for Methods and Tools:
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Contact: nccmt@mcmaster.ca