Background
“… strategies to improve professional practice that are planned, taking account of prospectively identified determinants of practice. Determinants of practice are factors that could influence the effectiveness of an intervention … and have been … referred to [as] barriers, obstacles, enablers, and facilitators [within the context in which the intervention occurs].”
“… can be effective, but the effect is variable and tends to be small to moderate. The number of studies remains small and more research is needed, including … studies to develop and investigate the components of tailoring (identification of the most important determinants, selecting interventions to address the determinants).”
Methods
Recruitment
Procedure
Results
Participants
Endorsement of strategies
Level* | ERIC strategy | Endorsements | |
---|---|---|---|
n = 25 respondents | |||
Count | Percentage (%) | ||
1 | Develop and implement tools for quality monitoring | 15 | 60 |
1 | Audit and provide feedback | 14 | 56 |
2 | Develop and organize quality monitoring systems | 10 | 40 |
2 | Facilitate relay of clinical data to providers | 9 | 36 |
2 | Obtain and use patients/consumers and family feedback | 7 | 28 |
2 | Organize clinician implementation team meetings | 7 | 28 |
2 | Purposely reexamine the implementation | 7 | 28 |
2 | Use data experts | 7 | 28 |
2 | Capture and share local knowledge | 6 | 24 |
2 | Facilitation | 5 | 20 |
Change record system | 4 | 16 | |
Conduct ongoing training | 4 | 16 | |
Develop a formal implementation blueprint | 4 | 16 | |
Provide local technical assistance | 4 | 16 | |
Assess for readiness and identify barriers and facilitators | 3 | 12 | |
Conduct cyclical small tests of change | 3 | 12 | |
Tailor strategies | 3 | 12 | |
Use an implementation adviser | 3 | 12 | |
Use data warehousing techniques | 3 | 12 | |
Use train the trainer strategies | 3 | 12 | |
Build a coalition | 2 | 8 | |
Conduct local consensus discussions | 2 | 8 | |
Create a learning collaborative | 2 | 8 | |
Identify and prepare champions | 2 | 8 | |
Inform local opinion leaders | 2 | 8 | |
Involve executive boards | 2 | 8 | |
Prepare patients/consumers to be active participants | 2 | 8 | |
Provide ongoing consultation | 2 | 8 | |
Recruit, designate, and train for leadership | 2 | 8 | |
Conduct educational meetings | 1 | 4 | |
Conduct educational outreach visits | 1 | 4 | |
Conduct a local needs assessment | 1 | 4 | |
Develop academic partnerships | 1 | 4 | |
Develop disincentives | 1 | 4 | |
Intervene with patients/consumers to enhance uptake and adherence | 1 | 4 | |
Involve patients/consumers and family members | 1 | 4 | |
Place innovation on a fee for service lists/formularies | 1 | 4 | |
Provide clinical supervision | 1 | 4 | |
Revise professional roles | 1 | 4 | |
Stage implementation scale up | 1 | 4 | |
Start a dissemination organization | 1 | 4 | |
Use capitated payments | 1 | 4 | |
Work with educational institutions | 1 | 4 |
CFIR construct | Barrier description | No. ERIC strategies | |
---|---|---|---|
Level 1 | Level 2 | ||
Intervention source | Stakeholders have a negative perception of the innovation because of the entity that developed it and/or where it was developed. | 0 | 9 |
Evidence strength and quality | Stakeholders have a negative perception of the quality and validity of evidence supporting the intervention. | 0 | 10 |
Relative advantage | Stakeholders do not see the advantage of implementing the innovation compared to an alternative solution or keeping things the same. | 0 | 11 |
Adaptability | Stakeholders do not believe that the innovation can be sufficiently adapted, tailored, or re-invented to meet local needs. | 1 | 10 |
Trialability | Stakeholders believe they cannot test the innovation on a smaller scale within the organization or undo implementation if needed. | 0 | 10 |
Complexity | Stakeholders believe that the innovation is complex based on their perception of duration, scope, radicalness, disruptiveness, centrality, and/or intricacy and number of steps needed to implement. | 0 | 15 |
Design quality and packaging | Stakeholders believe the innovation is poor quality based on the way it is bundled, presented, and/or assembled. | 0 | 7 |
Cost | Stakeholders believe the innovation costs and/or the costs to implement (including investment, supply, and opportunity costs) are too high. | 1 | 9 |
Patient needs and resources | Patient needs, including barriers and facilitators to meet those needs, are not accurately known and/or this information is not a high priority for the organization. | 3 | 5 |
Cosmopolitanism | The organization is not well networked with external organizations. | 3 | 7 |
Peer pressure | There is little pressure to implement the innovation because other key peers or competing organizations have not already implemented the innovation nor is the organization doing this in a bid for a competitive edge. | 0 | 8 |
External policy and incentives | External policies, regulations (governmental or other central entity), mandates, recommendations or guidelines, pay-for-performance, collaborative, or public or benchmark reporting do not exist or they undermine efforts to implement the innovation. | 0 | 7 |
Structural characteristics | The social architecture, age, maturity, and size of an organization hinder implementation. | 0 | 9 |
Networks and communications | The organization has poor quality or non-productive social networks and/or ineffective formal and informal communications. | 2 | 7 |
Culture | Cultural norms, values, and basic assumptions of the organization hinder implementation. | 1 | 12 |
Implementation climate | There is little capacity for change, low receptivity, and no expectation that the use of the innovation will be rewarded, supported, or expected. | 1 | 6 |
Tension for change | Stakeholders do not see the current situation as intolerable nor do not believe they need to implement the innovation. | 0 | 8 |
Compatibility | The innovation does not fit well with existing workflows nor with the meaning and values attached to the innovation, nor does it align well with stakeholders’ own needs and/or it heightens the risk for stakeholders. | 0 | 10 |
Relative priority | Stakeholders perceive that the implementation of the innovation takes a backseat to other initiatives or activities. | 0 | 6 |
Organizational incentives and rewards | There are no tangible (e.g., goal-sharing awards, performance reviews, promotions, salary raises) or less tangible (e.g., increased stature or respect) incentives in place for implementing the innovation. | 1 | 7 |
Goals and feedback | Goals are not clearly communicated or acted upon, nor do stakeholders receive feedback that is aligned with goals. | 1 | 6 |
Learning climate | The organization has a climate where (a) leaders do not express their own fallibility or need for stakeholders’ assistance or input; (b) stakeholders do not feel that they are essential, valued, and knowledgeable partners in the implementation process; (c) stakeholders do not feel psychologically safe to try new methods; and (d) there is not sufficient time and space for reflective thinking or evaluation. | 1 | 6 |
Readiness for implementation | There are few tangible and immediate indicators of organizational readiness and commitment to implement the innovation. | 1 | 6 |
Leadership engagement | Key organizational leaders or managers do not exhibit commitment and are not involved, nor are they held accountable for the implementation of the innovation. | 0 | 9 |
Available resources | Resources (e.g., money, physical space, dedicated time) are insufficient to support the implementation of the innovation. | 1 | 7 |
Access to knowledge and information | Stakeholders do not have adequate access to digestible information and knowledge about the innovation nor how to incorporate it into work tasks. | 3 | 7 |
Knowledge and beliefs about the intervention | Stakeholders have negative attitudes toward the innovation, they place low value on implementing the innovation, and/or they are not familiar with facts, truths, and principles about the innovation. | 1 | 11 |
Self-efficacy | Stakeholders do not have confidence in their capabilities to execute courses of action to achieve implementation goals. | 0 | 12 |
Individual stage of change | Stakeholders are not skilled or enthusiastic about using the innovation in a sustained way. | 0 | 12 |
Individual identification with organization | Stakeholders are not satisfied with and have a low level of commitment to their organization. | 0 | 9 |
Planning | A scheme or sequence of tasks necessary to implement the intervention has not been developed or the quality is poor. | 2 | 6 |
Opinion leaders | Opinion leaders (individuals who have a formal or informal influence on the attitudes and beliefs of their colleagues with respect to implementing the intervention) are not involved or supportive. | 2 | 6 |
Formally appointed internal implementation leaders | A skilled implementation leader (coordinator, project manager, or team leader), with the responsibility to lead the implementation of the innovation, has not been formally appointed or recognized within the organization. | 1 | 11 |
Champions | Individuals acting as champions who support, market, or “drive-through” implementation in a way that helps to overcome indifference or resistance by key stakeholders are not involved or supportive. | 1 | 6 |
External change agents | Individuals from an outside entity formally facilitating decisions to help move implementation forward are not involved or supportive. | 0 | 10 |
Key stakeholders | Multifaceted strategies to attract and involve key stakeholders in implementing or using the innovation (e.g., through social marketing, education, role modeling, training) are ineffective or non-existent. | 1 | 9 |
Patients/customers | Multifaceted strategies to attract and involve patients/customers in implementing or using the innovation (e.g., through social marketing, education, role modeling, training) are ineffective or non-existent. | 3 | 6 |
Executing | Implementation activities are not being done according to plan. | 0 | 12 |
Reflecting and evaluating | There is little or no quantitative and qualitative feedback about the progress and quality of implementation nor regular personal and team debriefing about progress and experience. | 2 | 8 |
Not influential (%) | Somewhat influential (%) | Extremely influential (%) | |
---|---|---|---|
Relevance (Does the strategy have direct relevance to the barrier?) | 0.0 | 14.8 | 85.2 |
Improvement opportunity (Will this strategy make a big impact?) | 1.6 | 34.4 | 63.9 |
Feasibility (Can the strategy realistically be applied to the barrier?) | 8.2 | 38.5 | 53.3 |
Validity (Is the evidence base for the strategy compelling?) | 13.1 | 62.3 | 24.6 |
Level of difficulty (What are the work and resource requirements for the strategy? | 27.9 | 51.6 | 20.5 |
Theme | Example quotes | % |
---|---|---|
Confidence in choices | I again have low confidence in my selections as a functional analysis of the low opinion [Evidence Strength & Quality] would be required to identify strategies to address. Difficult to only choose 7. I have moderate confidence in my ranking. | 12 |
Elaborating on choices | I think the items I chose are fairly strong supporters of adaptability. I think adaptability is dependent upon facilitation of inventiveness/adaptability by someone who knows both the setting and the intervention. Revising professionals’ roles supports adaptability, however, there is often such a struggle with understanding team roles, even without revision, this needs constant vigilance. This order of steps presumes that there is already someone who is familiar with the organization and intervention who could be trained for leadership within a relatively short time. Items 1 and 2 would be reversed if there are no clear candidates who could be recruited and trained to be an implementation leader, and this process would be facilitated by having an implementation blueprint in place. | 62 |
Issues related to CFIR barrier | This barrier is hard to envision, too. What exactly is the barrier? Is there an identified “champion” who is not supportive, creating passive resistance, or perhaps thinks he is helping but is actually hampering progress? Or is there just no champion. Again, involves very different processes. It’s not entirely clear to me what this barrier description means. I can read it several ways. Is there a practice, owned by a hospital, that is trying to implement a change but the hospital’s staff is not helping, or is actively opposed? Or is this an organization that should be getting change management help from, for example, a regional extension center but the REC is just ignoring them? / / Lacking more detail, I approached this from the perspective that the outside entity is unhelpful so the organization has to compensate internally. | 5 |
Issues related to context | The approach for these detail-less exercises would be easier to develop with more context or specific situation. … it seems to me that unless one understands the factors that contribute to the lack of incentives, it is not possible to recommend with any confidence the utility of different strategies to address the issue. Similarly, the phase of implementation at which this problem is observed would have implications for the strategies likely to be effective. For example, at the early exploration phase, the extent to which such incentives, concrete or symbolic, could be cultivated in the organization and service system would be a point of discussion. Alternatively, if an innovative practice is implemented but does not reach sustainment, and the lack of incentives is identified as a factor contributing to the lack of sustainment, then the strategies to address the problem would likely differ. | 7 |
Issues related to implementation strategies | Behavioral change strategies targeting motivation are lacking in the ERIC list. Not sure any of these strategies would rectify poor communication and networks. | 10 |
Technical issues | Website would not let me reorder this for some reason. Just an fyi. The order indicated here is close enough. The drag and drop functionality is super hard to work with in this survey. I have done my best on rank ordering but OY! What a pain! | 3 |
Nonspecific comments | OK Proverbs 29:18. When there is no vision, the people perish. [peer pressure] | 1 |
Discussion
Example application of the CFIR-ERIC tool
ERIC strategies | Cumulative percent (%) | Structural characteristics (%) | Networks and communications (%) | Compatibility | Organizational incentives and rewards (%) | Planning | Formally appointed internal implementation leaders (%) | Key stakeholders (%) |
---|---|---|---|---|---|---|---|---|
Identify and prepare champions |
248
|
27
| 17 |
21
|
25
|
31
|
64
|
63
|
Assess for readiness and identify barriers and facilitators |
205
|
36
| 13 |
34
| 13 |
42
|
29
|
38
|
Develop a formal implementation blueprint |
171
| 18 | 13 | 3 | 8 |
73
|
46
| 8 |
Conduct local consensus discussions |
164
| 14 |
22
|
41
| 8 |
23
| 14 |
42
|
Build a coalition |
143
|
27
|
39
|
21
| 17 | 4 | 11 |
25
|
Conduct local needs assessment |
137
| 18 | 9 |
21
| 8 |
50
| 11 |
21
|
Alter incentive/allowance structures |
135
| 18 | 0 | 10 |
71
| 12 | 7 | 17 |
Create a learning collaborative |
135
| 18 |
35
| 14 | 13 | 8 | 14 |
33
|
Organize clinician implementation team meetings |
129
| 14 |
52
| 14 | 8 | 15 |
21
| 4 |
Facilitation |
125
| 9 |
26
|
24
| 4 |
23
|
21
| 17 |
Recruit, designate, and train for leadership |
120
| 18 | 17 | 0 |
21
| 12 |
39
| 13 |
Inform local opinion leaders |
113
| 14 |
22
| 3 | 17 | 0 |
29
|
29
|
Identify early adopters |
112
|
23
| 17 | 10 | 13 | 12 |
25
| 13 |
Promote network weaving |
111
|
23
|
57
| 0 | 8 | 4 | 7 | 13 |
Tailor strategies |
105
| 18 | 4 |
38
| 17 | 12 | 0 | 17 |
Capture and share local knowledge |
102
|
23
|
26
| 14 | 8 | 15 | 4 | 13 |
Conduct cyclical small tests of change |
102
|
2
3
| 9 |
38
| 13 | 12 | 0 | 8 |
Promote adaptability |
88
|
23
| 0 |
45
| 4 | 0 | 0 | 17 |
Use advisory boards and workgroups |
87
| 5 | 13 | 3 | 4 | 15 |
21
|
2
5
|
Involve executive boards |
81
| 14 | 9 | 3 | 13 | 0 | 18 |
25
|
Use an implementation adviser |
72
| 5 | 9 | 10 | 0 | 15 |
29
| 4 |
Develop and implement tools for quality monitoring |
71
| 5 | 0 | 3 |
21
|
31
| 7 | 4 |
Access new funding |
69
| 5 | 4 | 3 |
38
| 8 | 7 | 4 |
Centralize technical assistance |
67
| 5 |
26
| 10 | 0 | 12 | 11 | 4 |
Obtain formal commitments |
67
| 9 | 9 | 0 | 13 | 4 |
29
| 4 |
Provide local technical assistance |
64
| 18 | 9 | 14 | 0 | 15 | 4 | 4 |
Purposely reexamine the implementation |
63
| 0 | 4 |
28
| 4 | 15 | 4 | 8 |
Revise professional roles |
59
| 18 | 0 | 10 | 13 | 0 | 18 | 0 |
Fund and contract for clinical innovation |
57
| 14 | 0 | 10 |
21
| 0 | 4 | 8 |
Conduct educational meetings |
56
| 5 | 13 | 10 | 0 | 8 | 0 |
21
|
Audit and provide feedback |
54
| 5 | 17 | 7 |
21
| 0 | 0 | 4 |
Involve patients/consumers and family members |
52
| 9 | 9 | 10 | 4 | 4 | 4 | 13 |
Stage implementation scale up |
51
| 14 | 0 | 10 | 4 | 15 | 7 | 0 |
Provide ongoing consultation |
50
| 9 | 0 | 3 | 4 | 4 |
21
| 8 |
Change physical structure and equipment | 43 |
32
| 0 | 7 | 4 | 0 | 0 | 0 |
Conduct ongoing training | 32 | 0 | 4 | 0 | 0 |
23
| 0 | 4 |
Use other payment schemes | 25 | 0 | 0 | 0 |
25
| 0 | 0 | 0 |