Process

The single most difficult domain to define, measure, or evaluate in implementation research is process. Theories from total quality management, integrated care, complexity theory, organizational learning, and others describe just how implementation (or change) should be enacted [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 components 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 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.

Check out Powell et al’s list of Expert Recommendations for Implementing Change (ERIC), which provides a compilation of implementation strategies. Waltz et al group these strategies into 9 clusters.