The activities and strategies used to implement the innovation.
Document the implementation process framework and/or activities and strategies being used to implement the innovation.

Distinguish the implementation process used to implement the innovation (activities that end after implementation is complete) from the innovation (the “thing” that continues when implementation is complete).

Approaches aimed at sustained implementation approaches vary widely (Lennox et al., 2018). Activities can be accomplished in any order, but the Dynamic Sustainability Framework describes an initial implementation phase that emphasizes getting structures and processes in place according to protocol (including first-order changes that include strategies and tasks to get the innovation initially running day-to-day; e.g., problem-solving, staffing allocations), ideally followed by a longer-term phase of sustained incremental optimization to increasingly improve fit of the innovation with context (including second-order changes to continuously improve by teams with a focus on increasingly deeply embedded processes to establish new routines (Chambers et al., 2013)). This approach helps to ensure sustained change (Reed et al., 2018).

The original CFIR elaborated further by highlighting that theories abound in how implementation (or change) should be enacted, embodied by theories of total quality management, integrated care, complexity theory, organizational learning, and others (R. P. Grol et al., 2007). Essential activities of the implementation process common across organizational change models and aligned with advances in implementation science are included in this domain. These activities may be accomplished formally or informally on a spectrum from bottom-up grassroots or top-down mandated change efforts. Often changes are made in a spiral, stop-and-start, or incremental approach to implementation (Van de Ven et al., 1999). Constructs broadly reflect the plan-do-study-act (adapt/abandon) (PDSA) approach to incremental testing and implementation (Institute for Healthcare Improvement, 2003; Perla et al., 2013): Planning, Doing, Reflecting and Evaluating, and then Adapting in response to the evaluation. Ideally, each activity is revisited, expanded, refined, and re-evaluated as needed, throughout the course of initial and sustained implementation.

Qualitative coding guidelines that are aligned with the Updated CFIR will be added in the future.

Regarding quantitative measurement of this domain: In a systematic review of quantitative measures related to implementation, Dorsey et al. identified four measures (Dorsey et al., 2021). Using PAPERS criteria of measurement quality with an aggregate scale ranging from -9 to +36 (Lewis, Mettert, Stanick, et al., 2021), The Implementation Phases Inventory (Bradshaw et al., 2009) had the highest score (10), followed closely by the Veterans Health Administration Continuous Quality Improvement Degree of Implementation Survey (V. A. Parker et al., 1999) with a score of 9. Results indicate the need for continued development of high-quality measures.

As we become aware of measures, we will post them here. Please contact us with updates.

Bradshaw, C. P., Debnam, K., Koth, C. W., & Leaf, P. (2009). Preliminary Validation of the Implementation Phases Inventory for Assessing Fidelity of Schoolwide Positive Behavior Supports. Journal of Positive Behavior Interventions, 11(3), 145–160.

Chambers, D. A., Glasgow, R. E., & Stange, K. C. (2013). The dynamic sustainability framework: Addressing the paradox of sustainment amid ongoing change. Implementation Science, 8(1), 117.

Dorsey, C. N., Mettert, K. D., Puspitasari, A. J., Damschroder, L. J., & Lewis, C. C. (2021). A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence. Implementation Research and Practice, 2, 263348952110024.

Grol, R. P., Bosch, M. C., Hulscher, M. E., Eccles, M. P., & Wensing, M. (2007). Planning and studying improvement in patient care: The use of theoretical perspectives. Milbank Q, 85(1), 93–138.

Institute for Healthcare Improvement. (2003). The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement (Innovation Series 2003, p. 20). Institute for Healthcare Improvement.

Lennox, L., Maher, L., & Reed, J. (2018). Navigating the sustainability landscape: A systematic review of sustainability approaches in healthcare. Implementation Science, 13(1), 27.

Lewis, C. C., Mettert, K. D., Stanick, C. F., Halko, H. M., Nolen, E. A., Powell, B. J., & Weiner, B. J. (2021). The psychometric and pragmatic evidence rating scale (PAPERS) for measure development and evaluation. Implementation Research and Practice, 2, 263348952110373.

Parker, V. A., Wubbenhorst, W. H., Young, G. J., Desai, K. R., & Charns, M. P. (1999). Implementing Quality Improvement in Hospitals: The Role of Leadership and Culture. American Journal of Medical Quality, 14(1), 64–69.

Perla, R. J., Provost, L. P., & Parry, G. J. (2013). Seven Propositions of the Science of Improvement: Exploring Foundations. Quality Management in Health Care, 22(3), 170–186.

Reed, J. E., Howe, C., Doyle, C., & Bell, D. (2018). Simple rules for evidence translation in complex systems: A qualitative study. BMC Medicine, 16(1), 92.

Van de Ven, A. H., Polley, D. E., Garud, R., & Vandataraman, S. (1999). The Innovation Journey. Oxford University Press.