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Background Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework. Methods User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2. Results The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent ( n  = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation. Conclusion The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances.

Background The challenges of implementing evidence-based innovations (EBIs) are widely recognized among practitioners and researchers. Context, broadly defined as everything outside the EBI, includes the dynamic and diverse array of forces working for or against implementation efforts. The Consolidated Framework for Implementation Research (CFIR) is one of the most widely used frameworks to guide assessment of contextual determinants of implementation. The original 2009 article invited critique in recognition for the need for the framework to evolve. As implementation science has matured, gaps in the CFIR have been identified and updates are needed. Our team is developing the CFIR 2.0 based on a literature review and follow-up survey with authors. We propose an Outcomes Addendum to the CFIR to address recommendations from these sources to include outcomes in the framework. Main text We conducted a literature review and surveyed corresponding authors of included articles to identify recommendations for the CFIR. There were recommendations to add both implementation and innovation outcomes from these sources. Based on these recommendations, we make conceptual distinctions between (1) anticipated implementation outcomes and actual implementation outcomes, (2) implementation outcomes and innovation outcomes, and (3) CFIR-based implementation determinants and innovation determinants. Conclusion An Outcomes Addendum to the CFIR is proposed. Our goal is to offer clear conceptual distinctions between types of outcomes for use with the CFIR, and perhaps other determinant implementation frameworks as well. These distinctions can help bring clarity as researchers consider which outcomes are most appropriate to evaluate in their research. We hope that sharing this in advance will generate feedback and debate about the merits of our proposed addendum.

Background Our research team has used the highly cited Consolidated Framework for Implementation Research (CFIR) a priori throughout the research process to better understand influences on implementation outcomes of an organizational change innovation to promote physical activity and healthy eating in faith-based settings. CFIR has recently been updated to include substantial changes in some domains and constructs, and our research team is preparing to carry out a new implementation study of an evidence-based innovation in churches. The purpose of this paper is to describe the process we undertook to map CFIR domains, constructs, and quantitative measures from our earlier studies onto updated CFIR domains, constructs, and quantitative measures for the new project, providing a model for other researchers. Methods The measurement team engaged in a systematic, structured, and iterative planning process that included the key actions of clarifying the goal for the transition process from CFIR to updated CFIR, reviewing/comparing CFIR and updated CFIR domains and constructs and how they changed, segmenting the five CFIR/updated CFIR domains for discussion and structuring each discussion with handouts in an iterative process, compiling the items from each domain, obtaining and incorporating feedback on the items from community partners, and compiling the final table of items that incorporates community input. Results The culmination of our process was a table that included updated CFIR domains and subdomains, constructs, survey respondents, and the data collection timeframe (baseline, post-training, and 32 weeks). Conclusions We offer our experience as a model for other implementation science research teams who wish to transition from CFIR to updated CFIR domains, subdomains, constructs, subconstructs, and associated quantitative measures to better understand implementation outcomes.

Background Qualitative approaches, alone or in mixed methods, are prominent within implementation science. However, traditional qualitative approaches are resource intensive, which has led to the development of rapid qualitative approaches. Published rapid approaches are often inductive in nature and rely on transcripts of interviews. We describe a deductive rapid analysis approach using the Consolidated Framework for Implementation Research (CFIR) that uses notes and audio recordings. This paper compares our rapid versus traditional deductive CFIR approach. Methods Semi-structured interviews were conducted for two cohorts of the Veterans Health Administration (VHA) Diffusion of Excellence (DoE). The CFIR guided data collection and analysis. In cohort A, we used our traditional CFIR-based deductive analysis approach (directed content analysis), where two analysts completed independent in-depth manual coding of interview transcripts using qualitative software. In cohort B, we used our new rapid CFIR-based deductive analysis approach (directed content analysis), where the primary analyst wrote detailed notes during interviews and immediately “coded” notes into a MS Excel CFIR construct by facility matrix; a secondary analyst then listened to audio recordings and edited the matrix. We tracked time for our traditional and rapid deductive CFIR approaches using a spreadsheet and captured transcription costs from invoices. We retrospectively compared our approaches in terms of effectiveness and rigor. Results Cohorts A and B were similar in terms of the amount of data collected. However, our rapid deductive CFIR approach required 409.5 analyst hours compared to 683 h during the traditional deductive CFIR approach. The rapid deductive approach eliminated $7250 in transcription costs. The facility-level analysis phase provided the greatest savings: 14 h/facility for the traditional analysis versus 3.92 h/facility for the rapid analysis. Data interpretation required the same number of hours for both approaches. Conclusion Our rapid deductive CFIR approach was less time intensive and eliminated transcription costs, yet effective in meeting evaluation objectives and establishing rigor. Researchers should consider the following when employing our approach: (1) team expertise in the CFIR and qualitative methods, (2) level of detail needed to meet project aims, (3) mode of data to analyze, and (4) advantages and disadvantages of using the CFIR.

Background A fundamental challenge of implementation is identifying contextual determinants (i.e., barriers and facilitators) and determining which implementation strategies will address them. Numerous conceptual frameworks (e.g., the Consolidated Framework for Implementation Research; CFIR) have been developed to guide the identification of contextual determinants, and compilations of implementation strategies (e.g., the Expert Recommendations for Implementing Change compilation; ERIC) have been developed which can support selection and reporting of implementation strategies. The aim of this study was to identify which ERIC implementation strategies would best address specific CFIR-based contextual barriers. Methods Implementation researchers and practitioners were recruited to participate in an online series of tasks involving matching specific ERIC implementation strategies to specific implementation barriers. Participants were presented with brief descriptions of barriers based on CFIR construct definitions. They were asked to rank up to seven implementation strategies that would best address each barrier. Barriers were presented in a random order, and participants had the option to respond to the barrier or skip to another barrier. Participants were also asked about considerations that most influenced their choices. Results Four hundred thirty-five invitations were emailed and 169 (39%) individuals participated. Respondents had considerable heterogeneity in opinions regarding which ERIC strategies best addressed each CFIR barrier. Across the 39 CFIR barriers, an average of 47 different ERIC strategies (SD = 4.8, range 35 to 55) was endorsed at least once for each, as being one of seven strategies that would best address the barrier. A tool was developed that allows users to specify high-priority CFIR-based barriers and receive a prioritized list of strategies based on endorsements provided by participants. Conclusions The wide heterogeneity of endorsements obtained in this study’s task suggests that there are relatively few consistent relationships between CFIR-based barriers and ERIC implementation strategies. Despite this heterogeneity, a tool aggregating endorsements across multiple barriers can support taking a structured approach to consider a broad range of strategies given those barriers. This study’s results point to the need for a more detailed evaluation of the underlying determinants of barriers and how these determinants are addressed by strategies as part of the implementation planning process.

Background In 2009, Damschroder et al. developed the Consolidated Framework for Implementation Research (CFIR), which provides a comprehensive listing of constructs thought to influence implementation. This systematic review assesses the extent to which the CFIR’s use in implementation research fulfills goals set forth by Damschroder et al. in terms of breadth of use, depth of application, and contribution to implementation research. Methods We searched Scopus and Web of Science for publications that cited the original CFIR publication by Damschroder et al. (Implement Sci 4:50, 2009) and downloaded each unique result for review. After applying exclusion criteria, the final articles were empirical studies published in peer-review journals that used the CFIR in a meaningful way (i.e., used the CFIR to guide data collection, measurement, coding, analysis, and/or reporting). A framework analysis approach was used to guide abstraction and synthesis of the included articles. Results Twenty-six of 429 unique articles (6 %) met inclusion criteria. We found great breadth in CFIR application; the CFIR was applied across a wide variety of study objectives, settings, and units of analysis. There was also variation in the method of included studies (mixed methods ( n  = 13); qualitative ( n  = 10); quantitative ( n  = 3)). Depth of CFIR application revealed some areas for improvement. Few studies ( n  = 3) reported justification for selection of CFIR constructs used; the majority of studies ( n  = 14) used the CFIR to guide data analysis only; and few studies investigated any outcomes ( n  = 11). Finally, reflections on the contribution of the CFIR to implementation research were scarce. Conclusions Our results indicate that the CFIR has been used across a wide range of studies, though more in-depth use of the CFIR may help advance implementation science. To harness its potential, researchers should consider how to most meaningfully use the CFIR. Specific recommendations for applying the CFIR include explicitly justifying selection of CFIR constructs; integrating the CFIR throughout the research process (in study design, data collection, and analysis); and appropriately using the CFIR given the phase of implementation of the research (e.g., if the research is post-implementation, using the CFIR to link determinants of implementation to outcomes).

Background Over 60 implementation frameworks exist. Using multiple frameworks may help researchers to address multiple study purposes, levels, and degrees of theoretical heritage and operationalizability; however, using multiple frameworks may result in unnecessary complexity and redundancy if doing so does not address study needs. The Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF) are both well-operationalized, multi-level implementation determinant frameworks derived from theory. As such, the rationale for using the frameworks in combination (i.e., CFIR + TDF) is unclear. The objective of this systematic review was to elucidate the rationale for using CFIR + TDF by (1) describing studies that have used CFIR + TDF, (2) how they used CFIR + TDF, and (2) their stated rationale for using CFIR + TDF. Methods We undertook a systematic review to identify studies that mentioned both the CFIR and the TDF, were written in English, were peer-reviewed, and reported either a protocol or results of an empirical study in MEDLINE/PubMed, PsycInfo, Web of Science, or Google Scholar. We then abstracted data into a matrix and analyzed it qualitatively, identifying salient themes. Findings We identified five protocols and seven completed studies that used CFIR + TDF. CFIR + TDF was applied to studies in several countries, to a range of healthcare interventions, and at multiple intervention phases; used many designs, methods, and units of analysis; and assessed a variety of outcomes. Three studies indicated that using CFIR + TDF addressed multiple study purposes. Six studies indicated that using CFIR + TDF addressed multiple conceptual levels. Four studies did not explicitly state their rationale for using CFIR + TDF. Conclusions Differences in the purposes that authors of the CFIR (e.g., comprehensive set of implementation determinants) and the TDF (e.g., intervention development) propose help to justify the use of CFIR + TDF. Given that the CFIR and the TDF are both multi-level frameworks, the rationale that using CFIR + TDF is needed to address multiple conceptual levels may reflect potentially misleading conventional wisdom. On the other hand, using CFIR + TDF may more fully define the multi-level nature of implementation. To avoid concerns about unnecessary complexity and redundancy, scholars who use CFIR + TDF and combinations of other frameworks should specify how the frameworks contribute to their study. Trial registration PROSPERO CRD42015027615

Background The Consolidated Framework for Implementation Research (CFIR) is a determinants framework that may require adaptation or contextualization to fit the needs of implementation scientists in low- and middle-income countries (LMICs). The purpose of this review is to characterize how the CFIR has been applied in LMIC contexts, to evaluate the utility of specific constructs to global implementation science research, and to identify opportunities to refine the CFIR to optimize utility in LMIC settings. Methods A systematic literature review was performed to evaluate the use of the CFIR in LMICs. Citation searches were conducted in Medline, CINAHL, PsycINFO, CINAHL, SCOPUS, and Web of Science. Data abstraction included study location, study design, phase of implementation, manner of implementation (ex., data analysis), domains and constructs used, and justifications for use, among other variables. A standardized questionnaire was sent to the corresponding authors of included studies to determine which CFIR domains and constructs authors found to be compatible with use in LMICs and to solicit feedback regarding ways in which CFIR performance could be improved for use in LMICs. Results Our database search yielded 504 articles, of which 34 met final inclusion criteria. The studies took place across 21 countries and focused on 18 different health topics. The studies primarily used qualitative study designs (68%). Over half (59%) of the studies applied the CFIR at study endline, primarily to guide data analysis or to contextualize study findings. Nineteen (59%) of the contacted authors participated in the survey. Authors unanimously identified culture and engaging as compatible with use in global implementation research. Only two constructs, patient needs and resources and individual stages of change were commonly identified as incompatible with use. Author feedback centered on team level influences on implementation, as well as systems characteristics, such as health system architecture. We propose a “Characteristics of Systems” domain and eleven novel constructs be added to the CFIR to increase its compatibility for use in LMICs. Conclusions These additions provide global implementation science practitioners opportunities to account for systems-level determinants operating independently of the implementing organization. Newly proposed constructs require further reliability and validity assessments. Trial registration PROSPERO, CRD42018095762

Background Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR). Methods We searched the literature for existing measures for the 7 Inner Setting domain constructs ( Culture Overall , Culture Stress , Culture Effort , Implementation Climate , Learning Climate , Leadership Engagement , and Available Resources ). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states ( N  = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity). Results CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤  α  < 0.9) to excellent ( α  ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level. Conclusions Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

Background Organizational readiness assessments have a history of being developed as important support tools for successful implementation. However, it remains unclear how best to operationalize readiness across varied projects or settings. We conducted a synthesis and content analysis of published readiness instruments to compare how investigators have operationalized the concept of organizational readiness for change. Methods We identified readiness assessments using a systematic review and update search. We mapped individual assessment items to the Consolidated Framework for Implementation Research (CFIR), which identifies five domains affecting implementation (outer setting, inner setting, intervention characteristics, characteristics of individuals, and implementation process) and multiple constructs within each domain. Results Of 1370 survey items, 897 (68%) mapped to the CFIR domain of inner setting, most commonly related to constructs of readiness for implementation ( n  = 220); networks and communication ( n  = 207); implementation climate ( n  = 204); structural characteristics ( n  = 139); and culture ( n  = 93). Two hundred forty-two items (18%) mapped to characteristics of individuals (mainly other personal attributes [ n  = 157] and self-efficacy [ n  = 52]); 80 (6%) mapped to outer setting; 51 (4%) mapped to implementation process; 40 (3%) mapped to intervention characteristics; and 60 (4%) did not map to CFIR constructs. Instruments were typically tailored to specific interventions or contexts. Discussion Available readiness instruments predominantly focus on contextual factors within the organization and characteristics of individuals, but the specificity of most assessment items suggests a need to tailor items to the specific scenario in which an assessment is fielded. Readiness assessments must bridge the gap between measuring a theoretical construct and factors of importance to a particular implementation.