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Contextual Frameworks for Research on the Implementation of Complex System Interventions
Methods Research Reports
Investigators: Lucia Rojas Smith, DrPH, MPH, Mahima Ashok, PhD, MS, Sydney Morss Dy, MD, MSc, Roberta C Wines, MPH, and Stephanie Teixeira-Poit, MS.
Author Information and AffiliationsStructured Abstract
Objectives:
This report presents the adaptation of the Consolidated Framework for Implementation Research (CFIR) to three complex system interventions involving (1) process redesign for improved efficiency and reduced costs (PR); (2) patient-centered medical homes (PCMH); and (3) care transitions. The purpose of the adapted frameworks— the PR Framework, PCMH Framework, and Care Transitions Framework—is to guide research on how, why, and where these interventions succeed or fail to achieve intended outcomes.
Data sources:
MEDLINE™. Additional studies were identified through the gray literature and technical experts.
Methods:
The adaptation was informed by the findings from a scan of selected literature on PR, PCMH, and care transitions, which included articles in MEDLINE, the published and gray literature, and recommendations of content experts at the Agency for Healthcare Research and Quality. A Technical Expert Panel (TEP) for each topic reviewed the draft of the contextual frameworks and provided input on the structure and content through a series of 2-hour calls. In addition, the PR and PCMH Frameworks were reviewed by two separate TEPs for usability. In total, five TEPs were convened for this work.
Results:
While retaining much of the CFIR's original structure and most of its original concepts, the revised frameworks address distinctive features of each of the three interventions. We added concepts relevant to each topic area, and more explicitly addressed the iterative and interactive nature of complex system change. We also modified nearly all the definitions of the CFIR constructs to incorporate terminology and examples tailored to the specific interventions. Two new domains were added to each of the frameworks—one for intermediary outcomes related to the implementation and one for outcomes of the interventions themselves. Several CFIR domains and constructs were renamed to be more resonant with the intervention's research target group. None of the original CFIR constructs were dropped, but several dozen new constructs were added across the three new frameworks. As these were iterative products, with initial PR and PCMH Frameworks informing the Care Transitions Framework, many of these new constructs overlap across the frameworks.
Conclusions:
These contextual frameworks provide a foundational taxonomy and conceptualization of key implementation constructs that researchers can use across studies to enhance their comparability and synthesis, thereby better informing the generalizability and replicability of specific interventions. In adapting the CFIR for complex system interventions, we thought it critical to include input from both research and practice stakeholders to ensure that the content is understandable and applicable to the intervention strategy of interest.
Contents
- Preface
- Acknowledgments
- Senior Advisors
- Technical Expert Panels
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Process Redesign Framework
- Patient-Centered Medical Home Framework
- Overview
- Organization of the Patient-Centered Medical Home Framework
- Modifications in the Patient-Centered Medical Home Framework
- Graphic Representation of the Patient-Centered Medical Home Framework
- How To Use the Patient-Centered Medical Home Framework
- Content of the Patient-Centered Medical Home Framework
- Applying the Patient-Centered Medical Home Framework: A Case Study
- Care Transitions Framework
- Discussion
- Conclusion
- References
- Glossary
- Appendix A Detailed Methods and Results of the Literature Scans
- Appendix B Included Articles From Literature Scans
- Appendix C Technical Expert Panel Composition, Methods, and Input on Usability
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10056-I. Prepared by: RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center, Research Triangle Park, NC
Suggested citation:
Rojas Smith L, Ashok M, Dy SM, Wines RC, Teixeira-Poit S. Contextual Frameworks for Research on the Implementation of Complex System Interventions. Methods Research Report. (Prepared by the RTI International– University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 14-EHC014-EF. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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.ahrq.gov
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