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RRP 12-494 – HSR&D Study

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RRP 12-494
Clarity out of Chaos: Synthesizing Implementation Findings
Laura J. Damschroder MPH
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: October 2013 - September 2014

BACKGROUND/RATIONALE:
This study's ultimate goal was to explore ways to move implementation science forward using the Consolidated Framework for Implementation Research (CFIR). Implementation studies, particularly those using qualitative methods, commonly have small sample sizes. Thus, the ability to merge findings across studies will greatly increase our ability to build a valuable knowledge base about what works where and why.

OBJECTIVE(S):
The aims of the project were:
1) to assess the use of the CFIR since its inception, and if feasible, using Qualitative Comparative Analysis (QCA) techniques to synthesize findings across studies;
2) to develop tools and approaches to assist implementation researchers who use the CFIR; and
3) to develop cross-walks between CFIR constructs and quantitative measures used by QUERI centers.

METHODS:
Aim 1: The project reviewed use of the CFIR through three sources of information. Findings from six Diabetes QUERI studies using the CFIR were aggregated to create a matrix of quantitative and qualitative findings for use in QCA. Second, a "lessons learned" synthesis conducted by CIPRS was explored for feasibility of adding their 73 studies to the QCA matrix. Third, a literature review of all published articles that cited the CFIR was conducted.

Aim 2: Two approaches were used to develop technical assistance for users of the CFIR. First, a set of annotated educational slides were created and disseminated. Second, our online CFIR website was significantly upgraded to include new tools and guidance to help users apply the CFIR in their work.

Aim 3: Two quantitative measurement instruments were identified to map their items to CFIR constructs. Qualitative coding techniques were used by a small group of experts who had deep knowledge of the CFIR and/or the measurement instrument being coded (aka mapped). Group consensus approaches were used to determine final mapping/coding decisions within a series of weekly one-hour sessions, spread over several months. This approach enabled the group to deliberate in depth about alternative decisions.

FINDINGS/RESULTS:
Aim 1: From the CIPRS synthesis, 27 of 40 authors of studies published between 2009-2012 responded to an email inquiry to obtain additional information needed to include their study in a QCA. None of the studies had sufficient information to include in the QCA. However, data from 129 interviews from 23 sites from six Diabetes QUERI studies were included in a QCA. One CFIR construct (reflecting and evaluating) and 4 combinations of constructs were found to be consistently associated with higher implementation effectiveness. Different constructs were significant depending on the intervention being implemented. A search of published peer-reviewed literature identified 364 articles that have cited the CFIR since 2009; 52 of those studies were deemed "significant" citations that indicated use of CFIR to guide aspects of the study: n=6 study protocols; n=16 syntheses; n=25 empirical studies; and n=5 substantive editorials.

Aim 2: A significantly upgraded website was launched that provides detailed guidance and tools to help users who apply the CFIR in their work: www.cfirguide.org. For example, an interview guide maker was developed that allows users to generate an interview guide based on the CFIR constructs they plan to assess. The beta version was presented to 28 implementation researchers from around the world who agreed to participate in one of four user feedback panels. In the panels, users engaged directly with the site based on user scenarios and recorded their overall impressions in a collaborative online site. We facilitated discussions for further detail and brainstormed solutions. Based on feedback from panel members, the site underwent further revisions. In addition to the panels, a series of meetings were held with representatives from each QUERI center to discuss the development of the website and to present and elicit feedback on a high level strategy for continuing to move the science of implementation forward in a collaborative way. The foundation has been laid to harness the work of all the QUERI centers to advance the science. These ideas have been encapsulated on the new website and provided the foundation for an approved RISOME project to develop tools to design tailored implementation strategies. In addition, an annotated slide set was developed for the VA Psychology Training Council committee that is charged with generating model curriculum recommendations and resources for VA Psychology Training Programs (internship and postdoc) nationwide.

Aim 3: Mapping of the Organizational Readiness for Change Assessment (ORCA) and the Organizational Change Manager (OCM) are complete and manuscripts are in process.

IMPACT:
The impacts of this study will be widespread within the implementation research community, allowing for refinement of measures, the synthesis of findings from multiple studies, deeper understanding of context, and education of researchers. Since the launch of the new CFIR website in October, 646 users have engaged in 955 sessions on the website. In published literature, over 300 articles have cited the CFIR. The influence of the CFIR continues to grow.

PUBLICATIONS:

VA Cyberseminars

  1. Damschroder LJ, Waltz T, Powell B. Expert Recommendations for Tailoring Strategies to Context. VA QUERI Implementation Network [Cyberseminar]. VA QUERI. 2015 Nov 5.


DRA: Health Systems
DRE: Prevention
Keywords: QUERI Implementation
MeSH Terms: none

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