The PARIHS framework
The PARIHS framework was developed to represent essential determinants of successful implementation of research into clinical practice [
1]. The PARIHS framework posits three core elements that determine the success of research implementation: (1) Evidence: the strength and nature of the evidence as perceived by multiple stakeholders; (2) Context: the quality of the context or environment in which the research is implemented, and (3) Facilitation: processes by which implementation is facilitated. Each of the three core elements, in turn, comprises multiple, distinct components.
Evidence includes four components, corresponding to different sources of evidence: (1) research evidence from published sources, or participation in formal experiments, (2) evidence from clinical experience or professional knowledge, (3) evidence from patient preferences or based on patient experiences, including those of caregivers and family; and (4) routine information derived from local practice context, which differs from professional experience in that it is the domain of the collective environment and not the individual [
4,
5]. While research evidence is often treated as the most heavily weighted form, the PARIHS framers emphasize that all four forms have meaning and constitute evidence from the perspective of users.
Context comprises three components: (1) organizational culture, (2) leadership, and (3) evaluation [
3,
5]. Culture refers to the values, beliefs, and attitudes shared by members of the organization, and can emerge at the macro-organizational level, as well as among sub-units within the organization. Leadership includes elements of teamwork, control, decision making, effectiveness of organizational structures, and issues related to empowerment. Evaluation relates to how the organization measures its performance, and how (or whether) feedback is provided to people within the organization, as well as the quality of measurement and feedback.
Facilitation is defined as a "technique by which one person makes things easier for others" which is achieved through "support to help people change their attitudes, habits, skills, ways of thinking, and working" [
1]. Facilitation is a human activity, enacted through roles. Its function is to help individuals and teams understand what they need to change and how to go about it [
2,
10]. That role may encompass a range of conventional activities and interventions, such as education, feedback and marketing [
10], though two factors appear to distinguish facilitation, as defined in PARIHS, from other multifaceted interventions. First, as its name implies, facilitation emphasizes enabling (as opposed to doing for others) through critical reflection, empathy, and counsel. Second, facilitation is expressly responsive and interactive, whereas conventional multi-faceted interventions do not necessarily involve two-way communication. Stetler and colleagues provide a pithy illustration from an interview[
10]:
On the site visit, I came in with a PowerPoint presentation. That is education. When they called me for help ... that was different. It was facilitation.
Harvey and colleagues propose that facilitation is an appointed role, as opposed to an opinion leader who is defined by virtue of his or her standing among peers [
2]. Prior publications have also distinguished facilitation roles filled by individuals internal versus external to the team or organization implementing the evidenced-based practice [
2,
10]. Internal facilitators are local to the implementation team or organization, and are directly involved in the implementation, usually in an assigned role. They can serve as a major point of interface with external facilitators [
10].
This distinction between internal and external facilitation may be particularly important in the context of assessing organizational readiness to change. Most prior publications on the PARIHS framework focused on external, rather than internal facilitation. (Stetler and colleagues even make the point of referring to internal facilitators by another name entirely: internal change agents [
10]). However, for the purposes of assessing organizational readiness to change, internal facilitation may be most pertinent, because it is a function of the organization, and is therefore a constant whereas the external facilitation can be designed or developed according to the needs of the organization. Assessing the organization or team's initial state becomes the first step in external facilitation, guiding subsequent facilitation activities. This notion is consistent with the recent suggestion by researchers that PARIHS be used in a two-stage process, to assess evidence and context in order to design facilitation interventions [
5].
The framers of PARIHS propose that the three core elements of evidence, context and facilitation have a cumulative effect [
6]. They suggested that no element be presumed inherently more important than the others until empirically demonstrated so [
1], and recently reiterated that relative weighting of elements and sub-elements is a key question that remains to be answered [
5].
Developing a diagnostic and evaluative tool based on PARIHS is a priority for researchers who developed the framework [
5]. Currently there are two published instruments based on PARIHS, both with important limitations.
The first is a survey to measure factors contributing to implementation of evidence-based clinical practice guidelines [
13]. The survey was developed by researchers in Sweden and comprises 23 items addressing clinical experience, patient's experience, and clinical context. The latter includes items about culture, leadership, evaluation and facilitation. At the present time, only test-retest measurement reliability has been assessed, though with generally favorable results (Kappa scores ranging from 0.39 to 0.80). However, the English translation of the survey hews closely to the language used in the conceptual articles on PARIHS, and the authors report that respondents had difficulty understanding some questions. Specifically, questions about facilitation and facilitators were confusing for some respondents. In addition, the survey omits measures of research evidence and combines measures of facilitation as part of context. The survey has not been validated beyond test-retest reliability.
The second instrument, the Context Assessment Index, is a 37-item survey to assess the readiness of a clinical practice for research utilization or implementation [
17]. The CAI scales were derived inductively from a multi-phase project combining expert panel input and exploratory factor analysis. The CAI comprises 5 scales: collaborative practice; evidence-informed practice; respect for persons; practice boundaries; and evaluation. It has been assessed using a sample of nurses from the Republic of Ireland and Northern Ireland, and found to have good internal consistency and test-retest reliability. However, the CAI measures general readiness for research utilization, rather than readiness for implementation of a specific, discrete practice change; the CAI is exclusively a measure of context, and does not assess perceptions of the evidence for a practice change. Also, although the items were based on PARIHS, the 5 scales were inductively derived and do not correspond with the conceptual sub-elements elaborated in the PARIHS writings. It is not clear what this means for the CAI as a measure of PARIHS elements.
The organizational readiness to change assessment (ORCA)
A survey instrument [see Additional file
1] was developed by researchers from the Veterans Affairs Ischemic Heart Disease Quality Enhancement Research Initiative [
18] for use in quality improvement projects as a tool for gauging overall site readiness and identifying specific barriers or challenges. The instrument grew out of the VA Key Players Study [
19], which was a post-hoc implementation assessment of the Lipid Measurement and Management System study [
20]. Interviews were conducted with staff at six study hospitals, each implementing different interventions, or sets of interventions, to improve lipid monitoring and treatment. The interviews revealed a number of common factors that facilitated or inhibited implementation, notably 1) communication among services; 2) physician prerogative in clinical care decisions; 3) initial planning for the intervention; 4) progress feedback; 5) specifying overall goals and evaluation of the intervention; 6) clarity of implementation team roles, 7) management support; and 8) resource availability.
IHD-QUERI investigators also referred to two other organizational surveys to identify major domains related to organizational change: 1) the Quality Improvement Implementation survey [
21,
22], a survey used to assess implementation of continuous quality improvement/total quality management in hospitals, and 2) the Service Line Research Project survey, which was used to assess implementation of service lines in hospitals [
23]. The former comprises 7 scales: leadership; customer satisfaction; quality management; information and analysis; quality results; employee quality training; employee quality and planning involvement. The latter includes six scales: satisfaction, information, outlook, culture for change, teamwork, and professional development.
The ORCA survey comprises three major scales corresponding to the core elements of the PARIHS framework: (1) Strength and extent of evidence for the clinical practice changes represented by the QI program, assessed with four subscales, (2) Quality of the organizational context for the QI program, assessed with six subscales, and (3) Capacity for internal facilitation of the QI program, assessed with nine subscales. Each subscale comprised between three and six items assessing a common dimension of the given scale. Below, we briefly introduce and describe each of the 19 subscales.
Evidence
The evidence scale comprised four subscales. The first scale consists of two items that are meant to measure discord within the practice team about the evidence, that is, the extent to which the respondent sees his or her colleagues concluding a weaker or stronger evidence base than the respondent. The other three subscales correspond to the three hypothesized components of evidence in the PARIHS framework: research evidence, clinical experience and patient preferences.
The instrument omits items measuring the fourth hypothesized component of evidence, that of "routine information." Routine information did not appear in the original model [
1], but was added in a 2004 update [
8], after the ORCA was developed.
Context
Context comprises six subscales. Two subscales assess dimensions of organizational culture: one for senior leadership or clinical management, and one for staff members. Two subscales assess leadership practice: one focused on formal leadership, particularly in terms of teambuilding, and one focused on attitudes of opinion leaders for practice change in general (as a measure of informal leadership practice). One subscale assesses evaluation in terms of setting goals, and tracking and communicating performance. Context items are assessed relative to change or quality of care generally, and not relative to the specific change being implemented. For example, one item refers to opinion leaders and whether they believe that the current practice patterns can be improved; this does not necessarily mean they believe the specific change being implemented can improve current practice. This is important for understanding whether barriers to implementation relate to the specific change being proposed or to changing clinical processes more generally. Measuring readiness as a function of both the specific change and general readiness is an approach used successfully in models of organizational readiness to change outside of health care [
24].
In addition, the ORCA includes a subscale measuring resources to support practice changes in general, once they had been made an organizational priority. General resources were added because research on organizational innovation suggests that slack resources, such as funds, staff time, facilities and equipment, are important determinants of successful implementation [
25]. Later publications on PARIHS include resources, such as human, technology, equipment and financial as part of a receptive context for implementation [
5].
Facilitation
Facilitation comprises nine elements focused on the organization's capacity for internal facilitation: (1) senior leadership management characteristics, such as proposing feasible projects and providing clear goals; (2) clinical champion characteristics, such as assuming responsibility for the success of the project and having authority to carry it out; (3) senior leadership or opinion leader roles, such as being informed and involved in implementation and agreeing on adequate resources to accomplish it; (4) implementation team member roles, such as having clearly defined responsibilities within the team and having release time to work on implementation; (5) implementation plan, such as having explicitly delineated roles and responsibilities, and obtaining staff input and opinions; (6) communication, such as having regular meetings with the implementation team, and providing feedback on implementation progress to clinical managers; (7) implementation progress, such as collecting feedback from patients and staff; (8) implementation resources, such as adequate equipment and materials, and incentives; and (9) implementation evaluation, such as staff and/or patient satisfaction, and review of findings by clinical leadership.