Strategy Design

Although the prospective use of the CFIR has been infrequent [1], the CFIR can be used to design an implementation strategy. After completing a context assessment and identifying barriers and facilitators to implementing an innovation, the CFIR can help tailor implementation strategies to mitigate barriers and leverage facilitators. This process can also be used to refine implementation processes through the course of implementation.

An overarching theory in Implementation Science states that implementation will be successful when implementation strategies are highly tailored and responsive to local context [2]. However, evidence supporting this theory is mixed [3,4], and authors have concluded that additional research is needed on how to appropriately tailor strategies in order to be able to accurately assess their effects [2,3].

Current research suggests that implementation strategies must be tailored over time to address multiple contextual levels [3]:

  • Individual level behavior change [5,6]
  • Collective (team, organization, etc.) level change [7-9]
  • Structural/policy/legal level change
Several systematic approaches to identify contextual barriers and facilitators and strategies to address them have been published [10-13].  We have taken these a step further with a publication that describes a new Strategy Matching Tool in the next section on this page. This Tool helps users choose strategies based on CFIR barriers. Complement this with Fernandez and colleagues’ 5-step Implementation Process to further operationalize your approach.

Using innovative trial designs and methods from other disciplines will help build the knowledge needed about how to tailor strategies:

  • “Agile science” methods [14]
  • Flexible adaptive intervention design [15-16]
  • Dynamic randomization of micro intervention components [17]

If you are using the CFIR to identify potential barriers to implementation, this knowledge can be used to help guide choice of implementation strategies to mitigate those barriers.

We have developed tool that helps you “match” strategies to barriers that were identified using the CFIR. Our open access article describes how this tool was developed and its limitations. This article is also highlighted in our Blog section.

Implementation strategies were drawn from the Expert Recommendations for Implementing Change (ERIC) list of strategies. These strategies are described within the following articles:

  • Powell et al 2015: This article lists all 73 ERIC strategies with short descriptions. Longer rationale and descriptions are documented in Additional File 6 published with this article.
  • Waltz et al 2015: This article groups 73 ERIC strategies into 9 clusters based on concept mapping methods.
  • Perry et al 2019: This article lists recommended refinements to the list of ERIC strategies based on findings from the ESCALATES National Evaluation. 

The CFIR-ERIC Matching tool was developed based on survey responses from “implementation experts” (n=169) who chose up to 7 implementation strategies they believed would best address each CFIR barrier. But respondents had considerable heterogeneity in opinions. The wide heterogeneity of endorsements obtained suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. More research is needed to better guide strategy choices.

Though consensus was not strong, this tool does provide a prioritized list of strategies to consider based on your knowledge of potential CFIR-based barriers. The matching tool will provide a list of implementation strategies to consider based on the CFIR-based barriers you enter.

Implementation Strategy Selection Tool

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Case illustration

An implementation evaluation of the Telephone Lifestyle Coaching program (TLC) was conducted within 11 Veterans Affairs (VA) medical centers [19]. This study identified seven determinants of implementation outcomes [20] based on a CFIR construct assessment.

The CFIR-ERIC Matching Tool can be used to select the seven CFIR barriers and generate a list of potential strategies to address those barriers. An output table (condensed to include strategies with the highest level of endorsement) lists the seven CFIR barriers across the top of the table. ERIC implementation strategies are listed in the first column. Strategies are sorted by cumulative level of endorsement. “Cumulative Percent” indicates the strength of endorsement for that strategy across all 7 CFIR barriers. For example, “Identify and Prepare Champions” has the highest cumulative endorsement (248%) for this strategy to address all 7 barriers. In fact, this strategy is color coded GREEN for 2 of the 7 barriers, indicating that a majority of respondents endorsed this strategy for those 2 barriers (Engaging: Formally Appointed Internal Implementation Leader & Engaging: Key Stakeholders) The YELLOW color coded cells indicate that at least 20% of respondents endorsed that strategy to address each of the indicated barriers.

  1. Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the consolidated framework for implementation research. Implementation Science. 2015 Dec;11(1):72.
  2. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implementation Science. 2013 Dec;8(1):117.
  3. See: https://implementationscience.biomedcentral.com/articles/10.1186/s13012-016-0536-x)
  4. Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N, Wensing M, Fiander M, Eccles MP, Godycki-Cwirko M, van Lieshout J, Jäger C. Tailored interventions to address determinants of practice. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD005470. DOI: 10.1002/14651858.CD005470.pub3.
  5. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation science. 2012 Dec;7(1):37.
  6. See: http://www.behaviourchangewheel.com
  7. Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, Proctor EK, Kirchner JE. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015 Dec;10(1):21.
  8. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, Proctor EK, Kirchner JE. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science. 2015 Aug 7;10(1):1.
  9. Waltz TJ, Powell BJ, Chinman MJ, Smith JL, Matthieu MM, Proctor EK, Damschroder LJ, Kirchner JE. Expert recommendations for implementing change (ERIC): protocol for a mixed methods study. Implementation Science. 2014 Dec;9(1):39.
  10. Powell BJ, Beidas RS, Lewis CC, Aarons GA, McMillen JC, Proctor EK, Mandell DS. Methods to improve the selection and tailoring of implementation strategies. The journal of behavioral health services & research. 2017 Apr 1;44(2):177-94.
  11. Colquhoun HL, Squires JE, Kolehmainen N, Fraser C, Grimshaw JM. Methods for designing interventions to change healthcare professionals’ behaviour: a systematic review. Implementation Science. 2017 Dec;12(1):30.
  12. See: https://interventionmapping.com/
  13. Lewis CC, Klasnja P, Powell B, Tuzzio L, Jones S, Walsh-Bailey C, Weiner B. From classification to causality: Advancing Understanding of Mechanisms of change in implementation science. Frontiers in public health. 2018;6:136.
  14. Hekler EB, Klasnja P, Riley WT, Buman MP, Huberty J, Rivera DE, Martin CA. Agile science: creating useful products for behavior change in the real world. Transl Behav Med. 2016 Jun; 6 (2): 317–28. doi: 10.1007/s13142-016-0395-7.
  15. Nahum-Shani I, Qian M, Almirall D, Pelham WE, Gnagy B, Fabiano GA, Waxmonsky JG, Y u J, Murphy SA. Experimental design and primary data analysis methods for comparing adaptive interventions. Psychological methods. 2012 Dec;17(4):457.
  16. Nahum-Shani I, Smith SN, Spring BJ, Collins LM, Witkiewitz K, Tewari A, Murphy SA. Just-in-time adaptive interventions (JITAIs) in mobile health: key components and design principles for ongoing health behavior support. Annals of Behavioral Medicine. 2017 Dec 12;52(6):446-62.
  17. Klasnja P, Hekler EB, Shiffman S, Boruvka A, Almirall D, Tewari A, Murphy SA. Microrandomized trials: An experimental design for developing just-in-time adaptive interventions. Health Psychology. 2015 Dec;34(S):1220.
  18. See: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=1060. Slide 49.
  19. Damschroder LJ, Reardon CM, Sperber N, Robinson CH, Fickel JJ, Oddone EZ. Implementation evaluation of the telephone lifestyle coaching (TLC) program: organizational factors associated with successful implementation. Translational behavioral medicine. 2016 Sep 29;7(2):233-41.
  20. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research. 2011 Mar 1;38(2):65-76.
  21. Proctor EK, Powell BJ, McMillen JC. Implementation strategies: recommendations for specifying and reporting. Implementation Science. 2013 Dec;8(1):139.

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