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 (Damschroder, Aron, et al. 2009) elaborated 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.