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Process - CFIR Wiki


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The single most difficult domain to define, measure, or evaluate in implementation research is process. Many theories abound in just how implementation (or change) should be enacted embodied by theories of total quality management, integrated care, complexity theory, organizational learning, and others[1]. These approaches may be somewhat prescriptive, geared toward “what works.” The CFIR’s main goal is to foster knowledge-building into why implementations succeed or fail[2]. The CFIR is agnostic to any particular prescribed implementation approach. However, most approaches have four components in common (though sometimes only implicitly): planning, engaging, executing, and reflecting and evaluating. We provide relatively broad definitions for each of these areas because there are many process paths to effective implementation; from pre-planned sequential steps to rapid cycle improvements with quick and brief plans for small incremental tests to covert grass-roots efforts. The process of implementation is transient, by definition. Small efforts may produce deep and broad improvements while large efforts may result in little to no improvements[3]. We argue that regardless of where any particular implementation process lays on this continuum, success is most likely in the presence of these four constructs. The four constructs together echo the four component of the PDSA cycle that is a part of the quality improvement paradigm[4]: Plan, Do (execute), Study (reflect and evaluate), and Act (adjust the plan and/or execute, as appropriate). We have added engagement as a highlighted part of a cyclical approach because of the importance of engaging key individuals strategically in the process. The four constructs, plan, engage, execute, along with reflect and evaluate are often done in an incremental or spiral approach to implementation – there may be fits and starts with many iterations of complete and incomplete cycles to accomplish implementation (as depicted in Figure 1 in the main paper).

The CFIR takes a broader view of process than is implied by the PARiHS model’s use of “facilitation.” Kitson, et al assert that facilitation should be informed by the findings of the content and context analysis[5]. The CFIR defines process that includes facilitation as one potential mechanism in the process of connecting an intervention and setting with effective implementation.

As stated in the main paper, rarely, are the four process activities done in order and are not meant to be sequential. Nearly always, these four activities are done in a spiral or incremental approach to implementation; each activity will be revisited, expanded, refined, and re-evaluated throughout implementation. These constructs can be studied from the perspective of an observer or can be used to guide planning and execution. The more effectively each of the four mechanisms is carried out, the more effective implementation will be.

A recent compilation of implemenatation strategies was published: Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., et al. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review, 69(2), 123-157. doi: 10.1177/1077558711430690

With a presentation online:

Associated Constructs


  1. 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, 85:93-138.
  2. Institute of Medicine (IOM): The state of quality improvement and implementation research: Expert views. Workshop summary. Washington, DC: The National Academies Press; 2007.
  3. Burnes B: Complexity theories and organizational change. International Journal of Management Reviews 2005, 7:73-90.
  4. IHI: The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement. In Innvation Series 2003. pp. 20. Cambridge, MA: Institutue for Healthcare Improvement; 2003:20.
  5. Kitson AL, Rycroft-Malone J, Harvey G, McCormack B, Seers K, Titchen A: Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges. Implement Sci 2008, 3:1.
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