_2025-03-27 _{#implementation-science #concept-sketch} _{[[maps-of-content]]} # Implementation Science: Understanding Theories, Models, and Frameworks 🎬 [[implementation-science-tools.excalidraw.svg|Concept Sketch: Implementation Tool]] 🗝️ [[implementation-science-theories-models-frameworks-key-terms|Key Terms: Implementation Science]] > [!abstract]- Learning Objectives > > - Differentiate between theories, models, and frameworks in [[implementation-science|implementation science]] > - Identify the five main categories of implementation science tools > - Understand how process models guide implementation journeys > - Recognize how determinants frameworks identify factors influencing implementation > - Apply evaluation frameworks to measure implementation success > - Distinguish between classic theories and implementation theories > - Connect these concepts to practical implementation challenges > > [!example]- Prerequisites > > - Basic understanding of research-to-practice challenges > - Familiarity with healthcare, public health, or social service delivery systems > - Interest in improving how [[implementation-and-evidence|evidence-based practices]] are adopted in real-world settings >[!audio]- Audio: Deep Dive Conversation Part 1 > > > >[!audio]- Audio: Deep Dive Conversation Part 2 > > > ## Introduction to Implementation Science Tools **Implementation science offers structured approaches to bridge the gap between research and practice.** While the field provides powerful tools for understanding and guiding implementation efforts, the abundance of theories, models, and frameworks—over 100 documented approaches—can feel overwhelming to newcomers. This guide aims to provide clarity by organizing these concepts into manageable categories and explaining their practical applications. ### Key Terminology: Theories, Models, and Frameworks Before diving deeper, let's establish clear definitions of the fundamental tools in implementation science: 1. **Theories** are explanatory tools that tell us **why** implementation succeeds or fails. They explain causal relationships and mechanisms behind implementation outcomes. 2. **Models** are simplifications that describe **how** implementation unfolds. They typically outline steps or stages in implementation processes to guide practitioners through complex changes. 3. **Frameworks** provide structured approaches for **what** to consider during implementation. They offer categories, constructs, or domains to organize thinking about implementation factors and outcomes. > [!important] Key: Notice how implementation science tools address different questions: > > - **Process models** address: "What steps should we follow?" > - **Determinants frameworks** address: "What factors might influence our success?" > - **Evaluation frameworks** address: "How do we measure implementation success?" > - **Classic theories** address: "Why do people and organizations change?" > - **Implementation theories** address: "Why does implementation vary across settings?" ## The Five Categories of Implementation Tools Implementation science tools can be organized into five distinct categories based on the research questions they address: 1. **Process Models**: Guide the translation of research into practice through defined stages 2. **Determinants Frameworks**: Identify factors that influence implementation outcomes 3. **Classic Theories**: Explain implementation variation using theories from other disciplines 4. **Implementation Theories**: Explain implementation variation using theories developed specifically for implementation science 5. **Evaluation Frameworks**: Guide the assessment of implementation efforts and outcomes Understanding which category best fits your needs will help you select the most appropriate tools for your implementation challenge. > [!connection]- Concept Connections > > These five categories aren't isolated—they complement each other throughout the implementation journey: > > - Process models often incorporate determinants at various stages > - Evaluation frameworks measure outcomes that theories attempt to explain > - Implementation theories frequently build upon classic theories from other fields > [!success] [[implementation-science-tools.excalidraw.svg|Implementation Science Tools Map]] > ![[implementation-science-tools.excalidraw.svg]] ## Process Models: Mapping the Implementation Journey **Process models provide roadmaps for implementation efforts by outlining key stages and transitions.** When practitioners ask, "Where do I start?" or "What comes next?" process models offer guidance by breaking down complex implementation efforts into manageable phases. ### Types of Process Models Process models can be categorized as: - **Action models**: Provide explicit guidance on what activities to perform at each stage - **Non-action models**: Specify stages but offer less prescriptive guidance on activities > [!visual]- Visual: Process Models > > Process models can be visualized as roadmaps with distinct milestones. Each milestone represents a stage in the implementation journey, with checkpoints indicating when you're ready to progress to the next stage. > ### Key Process Models in Implementation Science #### EPIS (Exploration, Preparation, Implementation, Sustainment) This non-action model divides implementation into four key stages: 1. **Exploration**: Assessing needs and the fit of potential innovations; ends with adoption decision 2. **Preparation**: Planning [[implementation-strategies|implementation strategies]] and securing stakeholder support 3. **Implementation**: Putting plans into action with focus on adoption and fidelity 4. **Sustainment**: Embedding the innovation into routine practice for long-term delivery > [!tip]- Application: EPIS > > EPIS can help implementation teams recognize where they are in the process and what transitional markers indicate readiness to move to the next phase. For example, securing necessary stakeholder buy-in marks completion of the Preparation phase. > #### Quality Improvement Framework (QIF) This action model provides more specific guidance with 14 critical steps across four phases aligned with EPIS. It emphasizes continuous learning and improvement through cyclical implementation. #### PRISM (Practical, Robust Implementation and Sustainability Model) PRISM focuses on identifying contextual factors important for both initial adoption and long-term sustainability, emphasizing the interplay between innovation characteristics and the environment. #### DAP (Dynamic Adaptation Process) This action model guides the process of adapting an intervention for use in a specific context. It helps identify core components that must be maintained for fidelity while allowing adaptation of other elements. #### DSF (Dynamic Sustainability Framework) This conceptual model views sustainability as an active, ongoing process requiring continuous learning and thoughtful adaptation rather than a static endpoint. > [!example]- Theory to Practice > > **Basic application**: A community health center uses EPIS to structure their diabetes prevention program implementation, identifying where they are in the process and what they need to accomplish before moving forward. > > **Intermediate application**: A school district implementing a new mental health screening program uses QIF to develop detailed action steps for each implementation phase, including specific responsibilities for staff members. > > **Advanced application**: A multi-site healthcare organization implements an evidence-based treatment using DAP to maintain core intervention components while adapting delivery methods to fit the unique context of each clinic. ## Determinants Frameworks: Understanding Implementation Influences **Determinants frameworks identify and categorize factors that may help or hinder implementation efforts.** Unlike theories, these frameworks are descriptive rather than causal—they specify what factors matter but not necessarily how they work together mechanistically. > [!abstract] Big Picture > > Determinants frameworks emerged from the need for a common language to identify implementation barriers and facilitators. They provide a structured way to anticipate, monitor, and address challenges across multiple system levels. > ### Key Applications of Determinants Frameworks Determinants frameworks serve several practical purposes: 1. Raising awareness of potential barriers and facilitators 2. Assessing the relative importance of different barriers 3. Monitoring challenges throughout the implementation process 4. Informing the selection of implementation strategies based on identified barriers > [!note]- Theoretical > > Determinants frameworks differ from theories in that they don't specify causal mechanisms. They are associational rather than explanatory, functioning more as classification systems for implementation influences. > ### Major Determinants Frameworks #### Theoretical Domains Framework (TDF) The TDF translates behavior change theories to understand individual-level change in implementation. It includes 84 constructs across 14 domains, focusing primarily on: - Individual cognition - Affective factors - Behavioral determinants While comprehensive at the individual level, TDF has fewer constructs related to organizational or system-level factors. #### Consolidated Framework for Implementation Research (CFIR) CFIR offers a more comprehensive framework with five domains: 1. **Intervention Characteristics**: Aspects of the innovation itself (evidence, complexity, cost) 2. **Individual Characteristics**: Attributes of those involved (knowledge, self-efficacy) 3. **Inner Setting**: Organizational context (culture, readiness, leadership) 4. **Outer Setting**: External factors (policies, patient needs, peer pressure) 5. **Process**: Implementation activities (planning, engaging, evaluating) CFIR provides broader coverage of systemic and contextual factors than TDF, making it useful for multi-level assessment. #### Tailored Implementation of Chronic Disease Checklist (TICD) Originally developed for chronic disease care implementation but adaptable more broadly, TICD comprises seven domains and 57 constructs, including: - Guideline factors - Health professional factors - Patient factors - Professional interactions - Incentives and resources - Organizational capacity - Social, legal, and political factors > [!example]- Theory to Practice > > **Basic application**: A clinic implementing a new screening protocol uses TDF to understand provider resistance, identifying knowledge gaps and competing priorities as key barriers. > > **Intermediate application**: A hospital adopting a new patient safety initiative uses CFIR to conduct a comprehensive assessment of barriers across all five domains, then prioritizes addressing leadership engagement and compatibility with existing workflows. > > **Advanced application**: A state public health department uses TICD to systematically analyze barriers to implementing evidence-based tobacco cessation programs across diverse healthcare settings, creating targeted implementation strategies for each identified barrier. > > [!tip]- Alternative Explanation > > Think of determinants frameworks as "implementation factor checklists" that help ensure you don't overlook important influences on your implementation success. Like a pre-flight checklist helps pilots ensure safety, determinants frameworks help implementation teams identify potential problems before they derail implementation efforts. > ## Evaluation Frameworks: Measuring Implementation Success **Implementation success is multifaceted and requires structured approaches to measurement.** Evaluation frameworks provide scaffolding for understanding how to assess both implementation processes and outcomes, acknowledging that implementation is both a means (process) and an end (outcome). > [!info] Context: > > Implementation evaluation serves purposes beyond determining "if it worked." It helps build knowledge about what implementation approaches work in what contexts, facilitating learning across projects and building implementation science as a field. > ### Key Evaluation Frameworks #### RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) This five-dimensional model captures the multifaceted nature of implementation success: 1. **Reach**: The extent to which the intended population participates 2. **Effectiveness**: The impact on targeted health outcomes 3. **Adoption**: The uptake by organizations or providers 4. **Implementation**: The fidelity with which the innovation is delivered 5. **Maintenance**: The sustainability of both outcomes and delivery RE-AIM has become the most widely recognized evaluation framework in implementation science. #### Implementation Outcomes Framework (IOF) This framework distinguishes between: - Implementation outcomes - Service outcomes - Client outcomes IOF identifies eight distinct implementation outcomes: 1. Acceptability 2. Adoption 3. Appropriateness 4. Cost 5. Feasibility 6. Fidelity 7. Penetration 8. Sustainability The framework proposes that implementation outcomes precede service outcomes (like efficiency and safety), which in turn precede client outcomes (like satisfaction and symptom improvement). > [!note]- Visual: > > An evaluation framework can be visualized as a dashboard with multiple gauges—each measuring a different aspect of implementation success. Just as a car's performance isn't judged by speed alone, implementation success isn't determined by a single metric. > [!note]- Practical > > Evaluation frameworks help answer questions like: > > - Did we reach the people we intended to serve? > - Did the intervention work as expected? > - Did organizations adopt the innovation? > - Was the innovation delivered as designed? > - Did the changes last over time? > > [!question]- Check Your Understanding > > How do evaluation frameworks differ from determinants frameworks? What unique value does each provide to implementation efforts? > ## Classic Theories: Borrowed Perspectives on Implementation **Implementation science draws from established theories in other disciplines to explain change processes.** These "classic theories" were developed in fields like psychology, sociology, and organizational science but provide valuable lenses for understanding implementation challenges. ### Levels of Classic Theories Classic theories operate at different system levels: #### Psychological Theories (Individual Level) Focus on individual-level change, including: - Health Belief Model - Social Cognitive Theory - Theory of Planned Behavior - Theories of habituation These theories help explain why individuals adopt or resist new practices. #### Sociological Theories (Interpersonal/Team Level) Examine group and team dynamics, including: - Social network theory - Social capital theory - Professional boundaries - Communities of practice These theories illuminate how social relationships influence implementation. #### Organizational Theories (Organizational Level) Help understand organizational change and interactions with external environments: - Institutional Theory - Resource Dependency Theory - Contingency Theory - Transaction Cost Economics These theories explain why organizations adopt innovations and how they integrate them into existing structures. #### Communication Theories (Cross-Cutting) Focus on knowledge construction and shared understanding: - Diffusion of Innovation Theory - Communication frameworks These theories explain how information about innovations spreads and is interpreted. > [!connection]- Concept Connections > > Classic theories often inform implementation theories and determinants frameworks. For example, [[diffusion-of-innovations-theory|Diffusion of Innovation]] concepts about innovation characteristics influence how we understand intervention adaptability in CFIR. > > [!tip]- Application > > When implementation efforts stall, classic theories can provide different perspectives on the problem: > > - Is this a matter of individual motivation? (psychological theories) > - Is this about group norms or team dynamics? (sociological theories) > - Is this related to organizational priorities or resources? (organizational theories) > - Is this about how the innovation is being communicated? (communication theories) > ## Implementation Theories: Native Explanations for Implementation Variation **Implementation theories are developed specifically to explain variation in implementation success.** Unlike borrowed theories, these "native theories" were created explicitly for implementation science, often focused on organizational-level factors that influence implementation outcomes. ### Key Implementation Theories #### Theory of Implementation Climate Stemming from organizational climate theory, this focuses on shared employee perceptions of an organization's policies and practices related to innovation. A stronger implementation climate—where policies and practices support, cultivate, and reward innovation—is hypothesized to drive more successful implementation efforts. > [!note]- Theoretical > Implementation climate is distinct from general organizational climate. It specifically refers to the shared perceptions about how much the organization values and supports the specific innovation being implemented. #### Theory of Organizational Readiness for Change This theory defines organizational readiness as a shared psychological state with two components: 1. **Change commitment**: Shared resolve to implement a change 2. **Change efficacy**: Collective belief in capability to implement the change Organizations with strong shared commitment and efficacy are theorized to have more successful implementation, as readiness drives more extensive and effective change-related efforts. #### Normalization Process Theory (NPT) NPT identifies and explains factors that promote or inhibit the integration of complex interventions into routine practice through four mechanisms: 1. **Coherence**: Making the innovation understandable to stakeholders 2. **Cognitive Participation**: Engaging people in using the innovation 3. **Collective Action**: Enacting the innovation with fidelity 4. **Reflexive Monitoring**: Assessing and responding to the innovation's impact NPT suggests that sustainable implementation requires all four mechanisms to function effectively. > [!example]- Theory to Practice > > **Basic application**: A clinic measures implementation climate before introducing a new evidence-based practice to identify potential areas of resistance. > > **Intermediate application**: A school district uses organizational readiness theory to assess and build both commitment and efficacy among teachers before implementing a new curriculum. > > **Advanced application**: A hospital system applies NPT to systematically address all four mechanisms when implementing a complex care coordination program, ensuring the program becomes normalized within existing workflows. > ## Bringing It All Together: An Integrated Approach **Effective implementation requires drawing from multiple theories, models, and frameworks to address different aspects of the implementation process.** Rather than viewing these tools as competing alternatives, skilled implementers integrate them to create comprehensive implementation approaches. > [!abstract] Big Picture > > The different categories of implementation science tools work together to answer complementary questions: > > - Process models tell us **what steps** to follow > - Determinants frameworks identify **what factors** influence success > - Evaluation frameworks guide **how to measure** our progress > - Classic theories explain **why people and organizations** change > - Implementation theories explain **why implementation varies** across settings > ### Practical Integration of Implementation Tools A comprehensive implementation approach might: 1. Use a **process model** (like EPIS) to structure the overall implementation journey 2. Apply a **determinants framework** (like CFIR) during the Exploration phase to assess barriers 3. Incorporate **classic theories** (like Diffusion of Innovation) to understand adoption patterns during Preparation 4. Apply **implementation theories** (like Organizational Readiness) to guide strategy selection 5. Use an **evaluation framework** (like RE-AIM) to monitor progress throughout the Implementation phase > [!tip]- Application > > When planning implementation: > > 1. Start with a process model to map your journey > 2. Use determinants frameworks early to identify potential barriers > 3. Apply relevant theories to understand and address specific challenges > 4. Select an evaluation framework that aligns with your implementation goals > 5. Revisit each tool throughout the implementation process as needs evolve > ### Case Example: Implementing a New Screening Protocol To illustrate how these tools work together, consider a healthcare system implementing a new depression screening protocol: 1. **Process Model Application**: Using EPIS to structure the implementation: - **Exploration**: Assessing current screening practices and needs - **Preparation**: Developing implementation strategies and training materials - **Implementation**: Rolling out the new protocol with monitoring and support - **Sustainment**: Embedding the protocol in electronic health records and staff onboarding 2. **Determinants Framework Application**: Using CFIR to identify potential barriers: - **Intervention**: Complexity of scoring and interpretation - **Individual**: Provider comfort with addressing mental health - **Inner Setting**: Competing priorities and time constraints - **Outer Setting**: Insurance reimbursement policies - **Process**: Need for champion engagement 3. **Theory Application**: - Using **Theory of Planned Behavior** to address provider hesitation - Applying **Implementation Climate** theory to foster supportive environment 4. **Evaluation Framework Application**: Using RE-AIM to track progress: - **Reach**: Percentage of eligible patients screened - **Effectiveness**: Improved detection and treatment rates - **Adoption**: Percentage of providers using the protocol - **Implementation**: Accuracy and consistency of screening delivery - **Maintenance**: Continued screening rates after initial implementation > [!example]- Theory to Practice > > **Application scenario**: A multi-site healthcare organization created an implementation toolkit that integrated these approaches. They used EPIS to structure their timeline, CFIR to conduct site assessments, Normalization Process Theory to develop site-specific strategies, and RE-AIM to create a balanced scorecard for measuring success. This integrated approach allowed them to tailor implementation while maintaining consistency in core implementation activities. > ## Common Implementation Challenges and Tool Selection **Different implementation challenges call for different implementation science tools.** Understanding which tools best address specific challenges can help implementers navigate complex situations more effectively. ### Challenge: Unsure Where to Start **Recommended Tools**: - **Process Models** (particularly action models like QIF) - **Structured planning approaches** based on Exploration phase activities > [!tip]- Application > When facing confusion about first steps, a process model provides structure and sequence, helping teams identify immediate actions while placing them in the context of the larger implementation journey. ### Challenge: Unexplained Implementation Failures **Recommended Tools**: - **Determinants Frameworks** to identify overlooked barriers - **Classic Theories** to understand resistance mechanisms - **Implementation Theories** to examine organizational factors > [!tip]- Application > Use determinants frameworks retrospectively to analyze what factors may have been missed in planning. Theories can then help explain why those factors influenced outcomes. ### Challenge: Difficulty Measuring Progress **Recommended Tools**: - **Evaluation Frameworks** to identify appropriate metrics - **Process Models** to establish implementation milestones > [!tip]- Application > Evaluation frameworks help shift focus from binary success/failure to multidimensional assessment, allowing teams to recognize partial successes and specific areas needing improvement. ### Challenge: Adaptation vs. Fidelity Tensions **Recommended Tools**: - **DAP (Dynamic Adaptation Process)** to guide thoughtful adaptation - **Fidelity assessment approaches** from evaluation frameworks > [!tip]- Application > These tools help teams identify core components that must be preserved while allowing contextual adaptation of peripheral elements. ## Key Takeaways > [!success] Key Takeaways > > - **Implementation science offers systematized approaches** to translate research into practice > - **Process models** provide roadmaps for implementation journeys > - **Determinants frameworks** identify factors influencing implementation success > - **Evaluation frameworks** provide structured approaches to measuring implementation progress > - **Classic theories** borrowed from other fields explain implementation from multiple perspectives > - **Implementation theories** developed specifically for the field explain variation in implementation success > - **Effective implementation draws from multiple tools** rather than relying on a single approach > - **Tool selection should align with specific implementation challenges** and contexts > [!note]- Visualization > A mind map connecting the five categories of implementation science tools would help visualize their relationships and complementary functions. The central node would be "Implementation Science Tools" with five main branches for each category, and sub-branches showing specific examples and their primary applications. > [!note]- Alt Text > > A mind map showing the five categories of implementation science tools (Process Models, Determinants Frameworks, Evaluation Frameworks, Classic Theories, and Implementation Theories) branching from a central "Implementation Science Tools" node, with specific examples and applications as sub-branches. ## Conclusion: Building Implementation Capacity **Implementation science tools provide structured approaches to complex implementation challenges, but their value lies in application rather than mere knowledge.** By understanding and appropriately applying theories, models, and frameworks, practitioners can move beyond trial-and-error approaches to more systematic implementation efforts. The field continues to evolve, with increasing emphasis on matching implementation strategies to specific contexts and barriers. The ultimate goal remains constant: to close the research-to-practice gap and ensure evidence-based innovations reach those who would benefit from them. As you apply these concepts in your work, remember that implementation science is itself an evolving practice. Approach each implementation challenge as an opportunity not only to improve practice but also to contribute to our collective understanding of what works, for whom, and under what conditions. -- Reference: - Dissemination and Implementation Science, UMich - Making sense of implementation theories, models and frameworks, Pier Nilsen