Fostering Implementation of Health Services Research Findings into Practice: A Consolidated Framework for Advancing Implementation Science

Abstract

Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.
We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.
The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.
The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

Full text

BioMed Central
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Implementation Science
Open Access
Research article
Fostering implementation of health services research findings into
practice: a consolidated framework for advancing implementation
science
Laura J Damschroder*1, David C Aron2, Rosalind E Keith1, Susan R Kirsh2,
Jeffery A Alexander3 and Julie C Lowery1
Address: 1HSR&D Center for Clinical Management Research, VA Ann Arbor Healthcare System (11H), 2215 Fuller Rd, Ann Arbor, MI 48105, USA,
2VA HSR&D Center for Quality Improvement Research (14W), Louis Stokes Cleveland DVAMC, 10701 East Blvd, Cleveland, OH 44106, USA and
3Health Management and Policy, School of Public Health, University of Michigan,109 S. Observatory (M3507 SPH II), Ann Arbor, Michigan
48109-2029, USA
Email: Laura J Damschroder* - laura.damschroder@va.gov; David C Aron - david.aron@va.gov; Rosalind E Keith - rekeith@umich.edu;
Susan R Kirsh - susan.kirsh@va.gov; Jeffery A Alexander - jalexand@umich.edu; Julie C Lowery - julie.lowery@va.gov
* Corresponding author
Abstract
Background: Many interventions found to be effective in health services research studies fail to translate into meaningful
patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative
outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs
sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help
promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a
comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology
and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research
(CFIR) that offers an overarching typology to promote implementation theory development and verification about what works
where and why across multiple contexts.
Methods: We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based
on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our
own findings, and potential for measurement. We combined constructs across published theories that had different labels but
were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.
Results: The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics
of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g.,
evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12
constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related
to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present
explicit definitions for each construct.
Conclusion: The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of
constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories.
It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.
Published: 7 August 2009
Implementation Science 2009, 4:50 doi:10.1186/1748-5908-4-50
Received: 5 June 2008
Accepted: 7 August 2009
This article is available from: http://www.implementationscience.com/content/4/1/50
© 2009 Damschroder et al., licensee BioMed Central Ltd.
This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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'To see far is one thing, going there is another' Constantin
Brancusi, 1876–1957
Background
Many interventions found to be effective in health services
research studies fail to translate into meaningful patient
care outcomes across multiple contexts. In fact, some esti-
mates indicate that two-thirds of organizations' efforts to
implement change fail [1]. Barriers to implementation
may arise at multiple levels of healthcare delivery: the
patient level, the provider team or group level, the organ-
izational level, or the market/policy level [2]. Researchers
must recognize the need to evaluate not only summative
endpoint health outcomes, but also to perform formative
evaluations to assess the extent to which implementation
is effective in a specific context to optimize intervention
benefits, prolong sustainability of the intervention in that
context, and promotes dissemination of findings into
other contexts [3]. Health services researchers are increas-
ingly recognizing the critical role of implementation sci-
ence [4]. For example, the United States Veterans Health
Administration (VHA) established the Quality Enhance-
ment Research Initiative (QUERI) in 1998 to 'systemati-
cally [implement]...clinical research findings and
evidence-based recommendations into routine clinical
practice' [5,6] and The National Institute for Health
Research Service Delivery and Organisation Program was
established to '...promote the uptake and application
of...evidence in policy and practice' in the United King-
dom.
Many implementation theories to promote effective
implementation have been described in the literature but
have differing terminologies and definitions. A compari-
son of theories reveals considerable overlap, yet each is
missing one or more key constructs included in other the-
ories. A comprehensive framework that consolidates con-
structs found in the broad array of published theories can
facilitate the identification and understanding of the myr-
iad potentially relevant constructs and how they may
apply in a particular context. Our goal, therefore, is to
establish the Consolidated Framework for Implementa-
tion Research (CFIR) that comprises common constructs
from published implementation theories. We describe a
theoretical framework that embraces, not replaces, the sig-
nificant and meaningful contribution of existing research
related to implementation science.
The CFIR is 'meta-theoretical'–it includes constructs from
a synthesis of existing theories, without depicting interre-
lationships, specific ecological levels, or specific hypothe-
ses. Many existing theories propose 'what works' but more
research is needed into what works where and why [7].
The CFIR offers an overarching typology–a list of con-
structs to promote theory development and verification
about what works where and why across multiple con-
texts. Researchers can select constructs from the CFIR that
are most relevant for their particular study setting and use
these to guide diagnostic assessments of implementation
context, evaluate implementation progress, and help
explain findings in research studies or quality improve-
ment initiatives. The CFIR will help advance implementa-
tion science by providing consistent taxonomy,
terminology, and definitions on which a knowledge base
of findings across multiple contexts can be built.
Methods
Developing a comprehensive framework is more chal-
lenging than simply combining constructs from existing
theories. We have carefully reviewed terminology and
constructs associated with published theories for this first
draft of the CFIR. In the process of standardizing termi-
nology, we have combined certain constructs across theo-
ries while separating and delineating others to develop
definitions that can be readily operationalized in imple-
mentation research studies.
We sought theories (we use the term theory to collectively
refer to published models, theories, and frameworks) that
facilitate translation of research findings into practice, pri-
marily within the healthcare sector. Greenhalgh et al.'s
synthesis of nearly 500 published sources across 13 fields
of research culminated in their 'Conceptual model for
considering the determinants of diffusion, dissemination,
and implementation of innovations in health service
delivery and organization' [8] and this was our starting
point for the CFIR. We used a snowball sampling
approach to identify new articles through colleagues
engaged in implementation research and theories that
cited Greenhalgh et al.'s synthesis, or that have been used
in multiple published studies in health services research
(e.g., the Promoting Action on Research Implementation
in Health Services (PARiHS) framework [9]). We included
theories related to dissemination, innovation, organiza-
tional change, implementation, knowledge translation,
and research uptake that have been published in peer
reviewed journals (one exception to this is Fixsen et al.'s
review published by the National Implementation
Research Network because of its scope and depth [10]).
We did not include practice models such as the Chronic
Care Model (CCM) because this describes a care delivery
system, not a model for implementation [11]. The CFIR
can be used to guide implementation of interventions that
target specific components of the CCM.
With few exceptions, we limited our review to theories
that were developed based on a synthesis of the literature
or as part of a large study. Our search for implementation
theories was not exhaustive but we did reach 'theme satu-
ration': the last seven models we reviewed did not yield

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new constructs, though some descriptions were altered
slightly with additional insights. We expect the CFIR to
continue to evolve as researchers use the CFIR and con-
tribute to the knowledge base.
The CFIR is a framework, which reflects a '...professional
consensus within a particular scientific community. It
stands for the entire constellation of beliefs, values, and
techniques shared by members of that community... [and]
need not specify the direction of relationships or identify
critical hypotheses' [12].
It is important to note the last clause: The CFIR specifies a
list of constructs within general domains that are believed
to influence (positively or negatively, as specified) imple-
mentation, but does not specify the interactions between
those constructs. The CFIR does provide a pragmatic
organization of constructs upon which theories hypothe-
sizing specific mechanisms of change and interactions can
be developed and tested empirically.
Table 1 lists the theories we reviewed for inclusion into
the CFIR. Greenhalgh et al.'s synthesis [8] was developed
based on an exhaustive synthesis of a wide range of litera-
tures including foundational work by Van de Ven, Rogers,
Damanpour, and others. This body of work is an impor-
tant foundation for the CFIR, though not explicitly listed
in Table 1. Constructs were selected for inclusion based on
strength of conceptual or evidential support in the litera-
ture for influencing implementation, high consistency in
definitions, alignment with our own experience, and
potential for operationalization as measures.
Foundational definitions
Implementation, context, and setting are concepts that are
widely used and yet have inconsistent definitions and
usage in the literature; thus, we present working defini-
tions for each. Implementation is the constellation of
processes intended to get an intervention into use within
an organization [13]; it is the means by which an interven-
tion is assimilated into an organization. Implementation
is the critical gateway between an organizational decision
to adopt an intervention and the routine use of that inter-
vention; the transition period during which targeted
stakeholders become increasingly skillful, consistent, and
committed in their use of an intervention [14].
Implementation, by its very nature, is a social process that
is intertwined with the context in which it takes place [15].
Context consists of a constellation of active interacting
variables and is not just a backdrop for implementation
[16]. For implementation research, 'context' is the set of
circumstances or unique factors that surround a particular
implementation effort. Examples of contextual factors
include a provider's perception of the evidence supporting
the use of a clinical reminder for obesity, local and
national policies about how to integrate that reminder
into a local electronic medical record, and characteristics
of the individuals involved in the implementation effort.
The theories underpinning the intervention and imple-
mentation [17] also contribute to context. In this paper,
we use the term context to connote this broad scope of cir-
cumstances and characteristics. The 'setting' includes the
environmental characteristics in which implementation
occurs. Most implementation theories in the literature use
the term context both to refer to broad context, as
described above, and also the specific setting.
Results
Overview of the CFIR
The CFIR comprises five major domains (the intervention,
inner and outer setting, the individuals involved, and the
process by which implementation is accomplished).
These domains interact in rich and complex ways to influ-
ence implementation effectiveness. More than 20 years
ago, Pettigrew and Whipp emphasized the essential inter-
active dimensions of content of intervention, context
(inner and outer settings), and process of implementation
[18]. This basic structure is also echoed by the PARiHS
framework that describes three key domains of evidence,
context, and facilitation [9]. Fixsen, et al. emphasize the
multi-level influences on implementation, from external
influencers to organizational and core implementation
process components, which include the central role of the
individuals who coach and train prospective practitioners
and the practitioners themselves [10].
The first major domain of the CFIR is related to character-
istics of the intervention being implemented into a partic-
ular organization. Without adaptation, interventions
usually come to a setting as a poor fit, resisted by individ-
uals who will be affected by the intervention, and requir-
ing an active process to engage individuals in order to
accomplish implementation. The intervention is often
complex and multi-faceted, with many interacting com-
ponents. Interventions can be conceptualized as having
'core components' (the essential and indispensible ele-
ments of the intervention) and an 'adaptable periphery'
(adaptable elements, structures, and systems related to the
intervention and organization into which it is being
implemented) [8,10]. For example, a clinical reminder to
screen for obesity has an alert that pops up on the compu-
ter screen at the appropriate time for the appropriate
patient. This feature is part of the core of the intervention.
Just as importantly, the intervention's adaptable periph-
ery allows it to be modified to the setting without under-
mining the integrity of that intervention. For example,
depending on the work processes at individual clinics, the
clinical reminder could pop up during the patient assess-
ment by a nurse case manager or when the primary care

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Table 1: Citation List of Models Analyzed for the CFIR
1 Conceptual Model for Considering the Determinants of Diffusion, Dissemination, and Implementation of Innovations in
Health Service Delivery and Organization
Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O: Diffusion of innovations in service organizations: systematic review
and recommendations. Milbank Q 2004, 82:581–629.
2 Conceptual Model for Implementation Effectiveness
Klein KJ, Sorra JS: The Challenge of Innovation Implementation. The Academy of Management Review 1996, 21:1055–1080.
Klein KJ, Conn AB, Sorra JS: Implementing computerized technology: An organizational analysis. J Appl Psychol 2001, 86:811–824.
3 Dimensions of Strategic Change
Pettigrew A, Whipp R: Managing change and corporate performance. In European Industrial Restructuring in the 1990s. Edited by Cool K,
Neven DJ, Walter I. Washington Square, NY: New York University Press; 1992: 227–265
4 Theory-based Taxonomy for Implementation
Leeman J, Baernholdt M, Sandelowski M: Developing a theory-based taxonomy of Methods for implementing change in practice. J
Adv Nurs 2007, 58:191–200.
5 PARiHS Framework: Promoting Action on Research Implementation in Health Services
Kitson A: From research to practice: one organisational model for promoting research based practice. Edtna Erca J 1997, 23:39–
45.
Rycroft-Malone J, Harvey G, Kitson A, McCormack B, Seers K, Titchen A: Getting evidence into practice: ingredients for change. Nurs
Stand 2002, 16:38–43.
6 Ottawa Model of Research Use
Graham ID, Logan J: Innovations in knowledge transfer and continuity of care. Can J Nurs Res 2004, 36:89–103.
7 Conceptual Framework for Transferring Research to Practice
Simpson DD: A conceptual framework for transferring research to practice. J Subst Abuse Treat 2002, 22:171–182.
Simpson DD, Dansereau DF: Assessing Organizational Functioning as a Step Toward Innovation. NIDA Science and Practice
Perspectives 2007, 3:20–28.
8 Diagnositic/Needs Assessment
Kochevar LK, Yano EM: Understanding health care organization needs and context. Beyond performance gaps. J Gen Intern Med
2006, 21 Suppl 2:S25–29.
9 Stetler Model of Research Utilization
Stetler CB: Updating the Stetler Model of research utilization to facilitate evidence-based practice. Nurs Outlook 2001, 49:272–
279.
10 Technology Implementation Process Model
Edmondson AC, Bohmer RM, Pisana GP: Disrupted routines: Team learning and new technology implementation in hospitals.
Adm Sci Q 2001, 46:685–716.
11 Replicating Effective Programs Framework
Kilbourne AM, Neumann MS, Pincus HA, Bauer MS, Stall R: Implementing evidence-based interventions in health care: Application
of the replicating effective programs framework. Implement Sci 2007, 2:42.
12 Organizational Transformation Model
VanDeusen Lukas CV, Holmes SK, Cohen AB, Restuccia J, Cramer IE, Shwartz M, Charns MP: Transformational change in health care
systems: An organizational model. Health Care Manage Rev 2007, 32:309–320.
13 Implementation of Change: A Model
Grol RP, Bosch MC, Hulscher ME, Eccles MP, Wensing M: Planning and studying improvement in patient care: the use of
theoretical perspectives. Milbank Q 2007, 85:93–138.
Grol R, Wensing M, Eccles M: Improving Patient Care: The Implementation of Change in Clinical Practice. Edinburgh, Scotland: Elsevier; 2005.
14 Framework of Dissemination in Health Services Intervention Research
Mendel P, Meredith LS, Schoenbaum M, Sherbourne CD, Wells KB: Interventions in organizational and community context: a
framework for building evidence on dissemination and implementation in health services research. Adm Policy Ment Health 2008,
35:21–37.

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provider evaluates the patient. Components of the periph-
ery can be modified to a particular setting and vice versa
in a co-evolving/co-adaptive way [19,20].
The next two domains in the CFIR are inner and outer set-
ting. Changes in the outer setting can influence imple-
mentation, often mediated through changes in the inner
setting [21]. Generally, the outer setting includes the eco-
nomic, political, and social context within which an
organization resides, and the inner setting includes fea-
tures of structural, political, and cultural contexts through
which the implementation process will proceed [22].
However, the line between inner and outer setting is not
always clear and the interface is dynamic and sometimes
precarious. The specific factors considered 'in' or 'out' will
depend on the context of the implementation effort. For
example, outlying clinics may be part of the outer setting
in one study, but part of the inner setting in another study.
The inner setting may be composed of tightly or loosely
coupled entities (e.g., a loosely affiliated medical center
and outlying contracted clinics or tightly integrated serv-
ice lines within a health system); tangible and intangible
manifestation of structural characteristics, networks and
communications, culture, climate, and readiness all inter-
relate and influence implementation.
The fourth major domain of the CFIR is the individuals
involved with the intervention and/or implementation
process. Individuals have agency; they make choices and
can wield power and influence on others with predictable
or unpredictable consequences for implementation. Indi-
viduals are carriers of cultural, organizational, profes-
sional, and individual mindsets, norms, interests, and
affiliations. Greenhalgh et al. describe the significant role
of individuals [8]:
'People are not passive recipients of innovations.
Rather...they seek innovations, experiment with them,
evaluate them, find (or fail to find) meaning in them,
develop feelings (positive or negative) about them,
challenge them, worry about them, complain about
them, 'work around' them, gain experience with them,
modify them to fit particular tasks, and try to improve
or redesign them–often through dialogue with other
users.'
Many theories of individual change have been published
[23], but little research has been done to gain understand-
ing of the dynamic interplay between individuals and the
organization within which they work, and how that inter-
play influences individual or organizational behavior
change. One recent synthesis of 76 studies using social
cognitive theories of behavior change found that the The-
ory of Planned Behavior (TPB) model was the most often
used model to explain intention and predict clinical
behavior of health professionals. The TPB, overall, suc-
ceeded in explaining 31% of variance in behavior [24].
The authors suggest that 'special care' is needed to better
define (and understand) the context of behavioral per-
formance. Frambach and Schillewaert's multi-level frame-
work is unique in explicitly acknowledging the multi-level
nature of change by integrating individual behavior
change within the context of organizational change [25].
Individuals in the inner setting include targeted users and
other affected individuals.
The fifth major domain is the implementation process.
Successful implementation usually requires an active
change process aimed to achieve individual and organiza-
tional level use of the intervention as designed. Individu-
als may actively promote the implementation process and
15 Conceptual Framework for Implementation of Defined Practices and Programs
Fixsen DL, Naoom, S. F., Blase, K. A., Friedman, R. M. and Wallace, F.: Implementation Research: A Synthesis of the Literature. (The
National Implementation Research Network ed.: University of South Florida, Louis de la Parte Florida Mental Health Institute; 2005.
16 Will it Work Here? A Decision-maker's Guide Adopting Innovations
Brach C, Lenfestey N, Roussel A, Amoozegar J, Sorensen A: Will It Work Here? A Decisionmaker's Guide to Adopting Innovations. Agency for
Healthcare Research and Quality (AHRQ); 2008.
17 Availability, Responsiveness and Continuity: An Organizational and Community Intervention Model
Glisson C, Schoenwald SK: The ARC organizational and community intervention strategy for implementing evidence-based
children's mental health treatments. Ment Health Serv Res 2005, 7:243–259.
Glisson C, Landsverk J, Schoenwald S, Kelleher K, Hoagwood KE, Mayberg S, Green P: Assessing the Organizational Social Context
(OSC) of Mental Health Services: Implications for Research and Practice. Adm Policy Ment Health 2008, 35:98–113.
18 A Practical, Robust Implementation and Sustainability Model (PRISM)
Feldstein AC, Glasgow RE: A practical, robust implementation and sustainability model (PRISM) for integrating research
findings into practice. Jt Comm J Qual Patient Saf 2008, 34:228–243.
19 Multi-level Conceptual Framework of Organizational Innovation Adoption
Frambach RT, Schillewaert N: Organizational innovation adoption: a multi-level framework of determinants and opportunities
for future research. Journal of Business Research 2001, 55:163–176.
Table 1: Citation List of Models Analyzed for the CFIR (Continued)

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may come from the inner or outer setting (e.g., local
champions, external change agents). The implementation
process may be an interrelated series of sub-processes that
do not necessarily occur sequentially. There are often
related processes progressing simultaneously at multiple
levels within the organization [22]. These sub-processes
may be formally planned or spontaneous; conscious or
subconscious; linear or nonlinear, but ideally are all
aimed in the same general direction: effective implemen-
tation.
In summary, the CFIR's overarching structure supports the
exploration of essential factors that may be encountered
during implementation through formative evaluations
[3,26]. Additional File 1 contains a figure that visually
depicts the five interrelated major domains. Using the five
major domains as an initial organizing structure (i.e.,
intervention, outer and inner setting, individuals
involved, and process), we mapped the broad array of
constructs described in Greenhalgh, et al.'s conceptual
model and the 18 additional theories listed in Table 1 to
constructs in the CFIR.
Detailed description of CFIR constructs
Some constructs appear in many of the theories included
in the CFIR (e.g., available resources appears in 10 of the
19 theories we reviewed), while others are more sparsely
supported (e.g., cost of the intervention only appears in
five of the 19 theories). Additional File 2 provides a table
that lists each published theory and the constructs
included in each theory. Additional File 3 provides a quick
reference table that lists each construct, along with a short
definition. Additional File 4 provides detailed rationale
for each construct.
Evaluation of most of the constructs relies on individual
perceptions. For example, it is one thing for an outside
expert panel to rate an intervention as having 'gold stand-
ard' level of evidence supporting its use. Stakeholders in
the receiving organization may have an entirely different
perception of that same evidence. It is the latter percep-
tions, socially constructed in the local setting, which will
affect implementation effectiveness. It is thus important
to design formative evaluations that carefully consider
how to elicit, construct, and interpret findings to reflect
the perceptions of the individuals and their organization,
not just the perceptions or judgments of outside research-
ers or experts.
Intervention characteristics
Intervention source
Perception of key stakeholders about whether the inter-
vention is externally or internally developed [8]. An inter-
vention may be internally developed as a good idea,
solution to a problem, or other grass-roots effort, or may
be developed by an external entity (e.g., vendor or
research group) [8]. The legitimacy of the source may also
influence implementation.
Evidence strength and quality
Stakeholders' perceptions of the quality and validity of
evidence supporting the belief that the intervention will
have desired outcomes. Sources of evidence may include
published literature, guidelines, anecdotal stories from
colleagues, information from a competitor, patient expe-
riences, results from a local pilot, and other sources
[9,27].
Relative advantage
Stakeholders' perception of the advantage of implement-
ing the intervention versus an alternative solution [28].
Adaptability
The degree to which an intervention can be adapted, tai-
lored, refined, or reinvented to meet local needs. Adapta-
bility relies on a definition of the 'core components' (the
essential and indispensible elements of the intervention
itself) versus the 'adaptable periphery' (adaptable ele-
ments, structures, and systems related to the intervention
and organization into which it is being implemented) of
the intervention [8,10], as described in the Overview sec-
tion. A component analysis can be performed to identify
the core versus adaptable periphery components [29], but
often the distinction is one that can only be discerned
through trial and error over time as the intervention is dis-
seminated more widely and adapted for a variety of con-
texts [26]. The tension between the need to achieve full
and consistent implementation across multiple contexts
while providing the flexibility for local sites to adapt the
intervention as needed is real and must be balanced,
which is no small challenge [30].
Trialability
The ability to test the intervention on a small scale in the
organization [8], and to be able to reverse course (undo
implementation) if warranted [31]. The ability to trial is a
key feature of the plan-do-study-act quality improvement
cycle that allows users to find ways to increase coordina-
tion to manage interdependence [32]. Piloting allows
individuals and groups to build experience and expertise,
and time to reflect upon and test the intervention [33],
and usability testing (with staff and patients) promotes
successful adaptation of the intervention [31].
Complexity
Perceived difficulty of implementation, reflected by dura-
tion, scope, radicalness, disruptiveness, centrality, and
intricacy and number of steps required to implement
[8,23]. Radical interventions require significant reorienta-
tion and non-routine processes to produce fundamental

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changes in the organization's activities and reflects a clear
departure from existing practices [8]. One way to deter-
mine complexity is by assessing 'length' (the number of
sequential sub-processes or steps for using or implement-
ing an intervention) and 'breadth' (number of choices
presented at decision points) [34]. Complexity is also
increased with higher numbers of potential target organi-
zational units (teams, clinics, departments) or types of
people (providers, patients, managers) targeted by the
intervention [34], and the degree to which the interven-
tion will alter central work processes [23].
Design quality and packaging
Perceived excellence in how the intervention is bundled,
presented, and assembled [35].
Cost
Costs of the intervention and costs associated with imple-
menting that intervention, including investment, supply,
and opportunity costs. It is important to differentiate this
construct from available resources (part of inner setting,
below). In many contexts, costs are difficult to capture and
available resources may have a more direct influence on
implementation.
Outer setting
Patient needs and resources
The extent to which patient needs, as well as barriers and
facilitators to meet those needs, are accurately known and
prioritized by the organization. Clearly, improving the
health and well-being of patients is the mission of all
healthcare entities, and many calls have gone out for
organizations to be more patient centered [21]. Patient-
centered organizations are more likely to implement
change effectively [36]. Many theories of research uptake
or implementation acknowledge the importance of
accounting for patient characteristics [31,33,37], and con-
sideration of patients needs and resources must be inte-
gral to any implementation that seeks to improve patient
outcomes [21]. The Practical, Robust Implementation and
Sustainability Model PRISM delineates six elements that
can help guide evaluation of the extent to which patients
are at the center of organizational processes and decisions:
patient choices are provided, patient barriers are
addressed, transition between program elements is seam-
less, complexity and costs are minimized, and patients
have high satisfaction with service and degree of access
and receive feedback [31].
Cosmopolitanism
The degree to which an organization is networked with
other external organizations. Organizations that support
and promote external boundary-spanning roles of their
staff are more likely to implement new practices quickly
[8]. The collective networks of relationships of individuals
in an organization represent the social capital of the
organization [38]. Social capital is one term used to
describe the quality and the extent of those relationships
and includes dimensions of shared vision and informa-
tion sharing. One component of social capital is external
bridging between people or groups outside the organiza-
tion [8].
Peer pressure
Mimetic or competitive pressure to implement an inter-
vention, typically because most or other key peer or com-
peting organizations have already implemented or in
pursuit of a competitive edge. 'Peers' can refer to any out-
side entity with which the organization feels some degree
of affinity or competition at some level within their organ-
ization (e.g., competitors in the market, other hospitals in
a network). The pressure to implement can be particularly
strong for late-adopting organizations [39].
External policies and incentives
Broad constructs that encompass external strategies to
spread interventions, including policy and regulations
(governmental or other central entity), external mandates,
recommendations and guidelines, pay-for-performance,
collaboratives, and public or benchmark reporting [26].
Inner setting
Contributing to the complexity inherent in describing the
many constructs related to the inner setting, are challenges
inherent in conceptualizing the myriad levels in which
these constructs influence and interact. Little systematic
research has been done to understand how constructs
apply to different levels within an organization, whether
constructs apply equally to all levels, and which constructs
are most important at which level.
Structural characteristics
The social architecture, age, maturity, and size of an
organization. Social architecture describes how large
numbers of people are clustered into smaller groups and
differentiated, and how the independent actions of these
differentiated groups are coordinated to produce a holistic
product or service [40]. Structural characteristics are, by-
and-large, quantitative measures and, in most cases, meas-
urement instruments and approaches have been devel-
oped for them. Damenpour conducted a meta-analysis of
many structural determinants based on 23 studies con-
ducted outside the healthcare sector [41]. Functional dif-
ferentiation is the internal division of labor where
coalitions of professionals are formed into differentiated
units. The number of units or departments represents
diversity of knowledge in an organization. The more sta-
ble teams are (members are able to remain with the team
for an adequate period of time; low turnover), the more
likely implementation will be successful [42]. Administra-

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tive intensity (the ratio of managers to total employees) is
positively associated with innovation [41]. Centralization
(the concentration of decision-making autonomy) has
been shown to be negatively associated with innovation
[41], but has also been found to be positive or negatively
associated, depending on the stage of intervention (initia-
tive stage versus implementation stage) [43]. Size, age,
maturity, and degree of specialization (the uniqueness of
the niche or market for the organization's products or
services) also influence implementation [8].
Networks and communications
The nature and quality of webs of social networks and the
nature and quality of formal and informal communica-
tions within an organization. Research on organizational
change has moved beyond reductionist measures of
organizational structure, and increasingly embraces the
complex role that networks and communications have on
implementation of change interventions [44]. Connec-
tions between individuals, units, services, and hierarchies
may be strong or weak, formal or informal, tangible or
intangible. Social capital describes the quality and the
extent of relationships and includes dimensions of shared
vision and information sharing. One component of social
capital is the internal bonding of individuals within the
same organization [8]. Complexity theory posits that rela-
tionships between individuals may be more important
than individual attributes [45], and building these rela-
tionships can positively influence implementation [46].
These relationships may manifest to build a sense of
'teamness' or 'community' that may contribute to imple-
mentation effectiveness [42].
Regardless of how an organization is structurally organ-
ized, the importance of communication across the organ-
ization is clear. Communication failures are involved with
the majority of sentinel events in US hospitals [47]. High
quality of formal communications contributes to effective
implementation [48]. Making staff feel welcome (good
assimilation), peer collaboration and open feedback and
review among peers and across hierarchical levels, clear
communication of mission and goals, and cohesion
between staff and informal communication quality, all
contribute to effective implementation [48].
Culture
Norms, values, and basic assumptions of a given organi-
zation [49]. Most change efforts are targeted at visible,
mostly objective, aspects of an organization that include
work tasks, structures, and behaviors. One explanation for
why so many of these initiatives fail centers on the failure
to change less tangible organizational assumptions,
thinking, or culture [50].
Some researchers have a relatively narrow definition of
culture, while other researchers incorporate nearly every
construct related to inner setting. In the next section we
highlight the concept of 'climate.' As with 'culture,' cli-
mate suffers from inconsistent definition. Culture and cli-
mate can, at times, be interchangeable across studies,
depending on the definition used [51]. A recent review
found 54 different definitions for organizational climate
[49] and, likewise, many definitions exist for culture [51].
Culture is often viewed as relatively stable, socially con-
structed, and subconscious [51]. The CFIR embraces this
latter view and differentiates climate as the localized and
more tangible manifestation of the largely intangible,
overarching culture [49]. Climate is a phenomenon that
can vary across teams or units, and is typically less stable
over time compared to culture.
Implementation climate
The absorptive capacity for change, shared receptivity of
involved individuals to an intervention [8], and the extent
to which use of that intervention will be 'rewarded, sup-
ported, and expected within their organization' [14]. Cli-
mate can be assessed through tangible and relatively
accessible means such as policies, procedures, and reward
systems [49]. Six sub-constructs contribute to a positive
implementation climate for an intervention: tension for
change, compatibility, relative priority, organizational
incentives and rewards, goals and feedback, and learning
climate.
1. Tension for change: The degree to which stakeholders
perceive the current situation as intolerable or needing
change [8,48].
2. Compatibility: The degree of tangible fit between
meaning and values attached to the intervention by
involved individuals, how those align with individuals'
own norms, values, and perceived risks and needs, and
how the intervention fits with existing workflows and sys-
tems [8,14]. The more individuals perceive alignment
between the meaning they attach to the intervention and
meaning communicated by upper management, the more
effective implementation is likely to be. For example, pro-
viders may perceive an intervention as a threat to their
autonomy, while leadership is motivated by the promise
of better patient outcomes.
3. Relative priority: Individuals' shared perception of the
importance of the implementation within the organiza-
tion [14,31,35].
4. Organizational incentives and rewards: Extrinsic incen-
tives such as goal-sharing awards, performance reviews,
promotions, and raises in salary, as well as less tangible
incentives such as increased stature or respect [35,52].

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5. Goals and feedback: The degree to which goals are
clearly communicated, acted upon, and fed back to staff
and alignment of that feedback with goals [34,48,53]. The
Chronic Care Model emphasizes the importance of rely-
ing on multiple methods of evaluation and feedback
including clinical, performance, and economic evalua-
tions and experience [11].
6. Learning climate: A climate in which: leaders express
their own fallibility and need for team members' assist-
ance and input; team members feel that they are essential,
valued, and knowledgeable partners in the change proc-
ess; individuals feel psychologically safe to try new meth-
ods; and there is sufficient time and space for reflective
thinking and evaluation (in general, not just in a single
implementation) [14,35,54]. These interrelated practices
and beliefs support and enable employee and organiza-
tional skill development, learning, and growth to maxi-
mize an organization's absorptive capacity for new
knowledge and methods [8]. Quantitative measurement
instruments are available for measuring an organization's
'learning' capability [55].
Readiness for implementation: Tangible and immediate
indicators of organizational commitment to its decision
to implement an intervention, consisting of three sub-
constructs (leadership engagement, available resources,
and access to information and knowledge). Implementa-
tion readiness is differentiated from implementation cli-
mate in the literature by its inclusion of specific tangible
and immediate indicators of organizational commitment
to its decision to implement an intervention. Additional
File 4 provides more discussion and rationale for the con-
stellation and grouping of sub-constructs for implementa-
tion climate and readiness for implementation.
1. Leadership engagement: Commitment, involvement,
and accountability of leaders and managers [35,53] with
the implementation. The term 'leadership' can refer to
leaders at any level of the organization, including execu-
tive leaders, middle management, front-line supervisors,
and team leaders, who have a direct or indirect influence
on the implementation. One important dimension of
organizational commitment is managerial patience (tak-
ing a long-term view rather than short-term) to allow time
for the often inevitable reduction in productivity until the
intervention takes hold [35].
2. Available resources: The level of resources dedicated for
implementation and ongoing operations including
money, training, education, physical space, and time
[8,28,42,48,56,57].
3. Access to information and knowledge: Ease of access to
digestible information and knowledge about the interven-
tion and how to incorporate it into work tasks [8]. Infor-
mation and knowledge includes all sources such as
experts, other experienced staff, training, documentation,
and computerized information systems.
Characteristics of individuals
Little research has been done to gain understanding of the
dynamic interplay between individuals and the organiza-
tion within which they work and how that interplay influ-
ences individual or organizational behavior change.
Organizations are, fundamentally, composed of individu-
als. However, the problem of the level of analysis is partic-
ularly clear when describing individual characteristics.
Though the characteristics described here are necessarily
measured at the individual level, these measures may be
most appropriately aggregated to team or unit or service
levels in analyses. The level at which to perform analysis
is determined by the study context. For example, Van-
Deusen Lukas, et al. measured knowledge and skills at an
individual level, but then aggregated this measure to the
team level in their study of factors influencing implemen-
tation of an intervention in ambulatory care clinics [58].
Organizational change starts with individual behavior
change. Individual knowledge and beliefs toward chang-
ing behavior and the level of self-efficacy to make the
change have been widely studied and are the two most
common individual measures in theories of individual
change [23]. The CFIR includes these two constructs along
with individual identification with the organization and
other personal attributes.
Knowledge and beliefs about the intervention
Individuals' attitudes toward and value placed on the
intervention, as well as familiarity with facts, truths, and
principles related to the intervention. Skill in using the
intervention is a primarily cognitive function that relies
on adequate how-to knowledge and knowledge of under-
lying principles or rationale for adopting the intervention
[59]. Enthusiastic use of an intervention can be reflected
by a positive affective response to the intervention. Often,
subjective opinions obtained from peers based on per-
sonal experiences are more accessible and convincing, and
these opinions help to generate enthusiasm [59]. Of
course, the converse is true as well, often creating a nega-
tive source of active or passive resistance [60]. The degree
to which new behaviors are positively or negatively valued
heightens intention to change, which is a precursor to
actual change [61].
Self-efficacy
Individual belief in their own capabilities to execute
courses of action to achieve implementation goals [62].
Self-efficacy is a significant component in most individual
behavior change theories [63]. Self-efficacy is dependent
on the ability to perform specific actions within a specific

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context. The more confident an individual feels about his
or her ability to make the changes needed to achieve
implementation goals, the higher their self-efficacy. Indi-
viduals with high self-efficacy are more likely to make a
decision to embrace the intervention and exhibit commit-
ted use even in the face of obstacles.
Individual stage of change
Characterization of the phase an individual is in, as he or
she progresses toward skilled, enthusiastic, and sustained
use of the intervention [23,35]. The specific stages used
will depend on the underlying model being used in the
study. Prochaska's trans-theoretical model characterizes
these stages as pre-contemplation, contemplation, prepa-
ration, and action and maintenance [64]. Rogers' diffu-
sion theory delineates five stages [59]. Grol et al. describe
a five-stage model with ten sub-stages based on their syn-
thesis of the literature [23].
Individual identification with organization
A broad construct related to how individuals perceive the
organization and their relationship and degree of com-
mitment to that organization. These attributes may affect
the willingness of staff to fully engage in implementation
efforts or use the intervention [65,66]. These measures
have been studied very little in healthcare, but may be
especially important when evaluating the influence of
implementation leaders' (described under Process below)
on implementation efforts. Organizational citizenship
behavior characterizes how well organizational identity is
taken on by individuals and whether, because they associ-
ate themselves with the organization, they are willing to
put in extra effort, talk well of the organization, and take
risks in their organization [67,68]. Organizational justice
is an individual's perception of distributive and proce-
dural fairness in the organization [65]. Emotional exhaus-
tion is an ongoing state of emotional and physical
depletion or burnout [69], and may negatively influence
implementation by stunting the ability and energy of an
individual to help or initiate change [70]. The Agency for
Healthcare Research and Quality recently published a
guide for determining whether a particular implementa-
tion will be successful that includes questions about indi-
vidual perceptions of whether they believe the
organization could be doing a better job, belief about
whether work is done efficiently, and whether there are
inequities as potential barriers to implementation [71].
The organizational social context measure, developed by
Glisson et al., includes constructs related to psychological
climate (perception of the psychological influence of
work environment) and work attitudes (job satisfaction
and organizational commitment) [72].
Other personal attributes
This is a broad construct to include other personal traits.
Traits such as tolerance of ambiguity, intellectual ability,
motivation, values, competence, capacity, innovativeness
[25], tenure [25], and learning style have not received ade-
quate attention by implementation researchers [8].
Process
We describe four essential activities of implementation
process that are common across organizational change
models: planning, engaging, executing, and reflecting and
evaluating. These activities may be accomplished formally
or informally through, for example, grassroots change
efforts. They can be accomplished in any order and are
often done in a spiral, stop-and-start, or incremental
approach to implementation [73]; e.g., using a plan-do-
study-act approach to incremental testing [74]. Each activ-
ity can be revisited, expanded, refined, and re-evaluated
throughout the course of implementation.
Planning
The degree to which a scheme or method of behavior and
tasks for implementing an intervention are developed in
advance and the quality of those schemes or methods. The
fundamental objective of planning is to design a course of
action to promote effective implementation by building
local capacity for using the intervention, collectively and
individually [26]. The specific steps in plans will be based
on the underlying theories or models used to promote
change at organization and individual levels [23]. For
example, the Institute for Healthcare Improvement
[74,75], Grol et al. [76], and Glisson and Schoenwald [77]
all describe comprehensive approaches to implementa-
tion on which implementation plans can be developed.
However, these theories prescribe different sets of activi-
ties because they were developed in different contexts–
though commonalities exist as well. Grol et al. list 14 dif-
ferent bodies of theories for changing behaviors in social
or organizational contexts [23], and Estabrooks et al. list
18 different models of organizational innovation [78].
Thus, the particular content of plans will vary depending
on the theory or model being used to guide implementa-
tion. Implementation plans can be evaluated by the
degree to which five considerations guide planning: stake-
holders' needs and perspectives are considered; strategies
are tailored for appropriate subgroups (e.g., delineated by
professional, demographic, cultural, organizational
attributes); appropriate style, imagery, and metaphors are
identified and used for delivering information and educa-
tion; appropriate communication channels are identified
and used; progress toward goals and milestones is tracked
using rigorous monitoring and evaluation methods
[8,59]; and strategies are used to simplify execution. The
latter step may include plans for dry runs (simulations or
practice sessions) to allow team members to learn how to

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use the intervention before going live [42], running trials
to allow users to test procedures, gain confidence, and
build an environment of psychological safety [42], or tak-
ing an incremental approach that breaks the intervention
down into manageable parts that can be implemented
incrementally [41]. The plan can be formal or informal
but should consider all salient contextual factors–both
modifiable and non-modifiable. Workarounds can be
developed for non-modifiable factors, and strategies can
be designed to change factors that can be modified (e.g.,
increase stakeholders' knowledge of the intervention).
Engaging
Attracting and involving appropriate individuals in the
implementation and use of the intervention through a
combined strategy of social marketing, education, role
modeling, training, and other similar activities. Engaging
members of teams tasked with implementing an interven-
tion (or to be 'first users') is an often overlooked part of
implementation [79]. It is vital that early members are
carefully and thoughtfully selected or allowed to rise nat-
urally [42,79], especially 'implementation leaders' and
'champions.' If early users and leaders are homophilous
(similar socioeconomic, professional, educational, and
cultural backgrounds) with intended users, individuals
will be more likely to adopt the intervention [8]. The
influence of these leaders can be evaluated by assessing
their presence or absence (e.g., does the implementation
effort have a clear champion or not?), how they are
brought on board (e.g., appointed, volunteered), their
role in the organization (formal and/or informal roles),
and their role in implementation. One means by which
influence is transmitted is role modeling [80]. We have
identified four types of implementation leaders. Terms
and definitions of roles vary widely in the literature. The
remainder of this section suggests standard definitions for
each:
1. Opinion leaders: Individuals in an organization who
have formal or informal influence on the attitudes and
beliefs of their colleagues with respect to implementing
the intervention [8,59]. There is general agreement that
there are two different types of opinion leaders, experts
and peers. Expert opinion leaders exert influence through
their authority and status [8]. Peer opinion leaders exert
influence through their representativeness and credibility
[8].
2. Formally appointed internal implementation leaders:
Individuals from within the organization who have been
formally appointed with responsibility for implementing
an intervention as coordinator, project manager, team
leader, or other similar role. These leaders may or may not
have explicit time dedicated to the task. Implementation
is 'part of the job.'
3. Champions: 'Individuals who dedicate themselves to
supporting, marketing, and 'driving through an [imple-
mentation]' [81], overcoming indifference or resistance
that the intervention may provoke in an organization. A
defining characteristic of champions is their willingness to
risk informal status and reputation because they believe
so strongly in the intervention [82]. The main distinction
of champions from opinion leaders is that champions
actively associate themselves with support of the interven-
tion during implementation. There is the old adage that
an intervention 'either finds a champion or dies' [83].
4. External change agents: Individuals who are affiliated
with an outside entity who formally influence or facilitate
intervention decisions in a desirable direction. They usu-
ally have professional training in a technical field related
to organizational change science or in the technology
being introduced into the organization. This role includes
outside researchers who may be implementing a multi-
site intervention study and other formally appointed indi-
viduals from an external entity (related or unrelated to the
organization); e.g., a facilitator from a corporate or
regional office or a hired consultant.
Executing
Carrying out or accomplishing the implementation
according to plan. Execution of an implementation plan
may be organic with no obvious or formal planning,
which makes execution difficult to assess. Quality of exe-
cution may consist of the degree of fidelity of implemen-
tation to planned courses of action [29], intensity (quality
and depth) of implementation [84], timeliness of task
completion, and degree of engagement of key involved
individuals (e.g., implementation leaders) in the imple-
mentation process.
Reflecting and evaluating
Quantitative and qualitative feedback about the progress
and quality of implementation accompanied with regular
personal and team debriefing about progress and experi-
ence. It is important to differentiate this processual con-
struct from the Goals and Feedback construct under Inner
Setting, described above. The focus here is specifically
related to implementation efforts. Evaluation includes tra-
ditional forms of feedback, such as reports, graphs, and
qualitative feedback and anecdotal stories of success [63].
Objectives should be specific, measurable, attainable, rel-
evant, and timely (the SMART rubric) [71]. Less attention
is paid in the literature to the need for, and value of, group
and personal reflection. Dedicating time for reflecting or
debriefing before, during, and after implementation is
one way to promote shared learning and improvements
along the way [42].

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Discussion
Process theories can be used to guide how implementa-
tion should be planned, organized, and scheduled, and
impact theories can be used to develop hypotheses about
how implementation activities will facilitate a desired
change[23] The CFIR is a pragmatic meta-theoretical
framework that can be used to complement these theories
with its comprehensive taxonomy of specific constructs
related to the intervention, inner and outer setting, indi-
viduals, and implementation process. For example, the
CFIR complements a process theory published by Pronov-
ost and colleagues from the Johns Hopkins Quality and
Safety Research Group for large-scale translation of scien-
tific evidence into practice that encompasses four major
steps [80]. The second step in this process theory is to
identify local barriers to implementation without specify-
ing what those barriers may be; the CFIR provides a list of
constructs to consider. The RE-AIM framework is used to
guide comprehensive evaluation of interventions in terms
of Reach, Effectiveness, Adoption, Implementation, and
Maintenance (sustainability) [85]. The CFIR opens the
'black box' of the 'I' (implementation) component.
The constructs described in the CFIR represent a begin-
ning foundation for understanding implementation.
Implementation researchers should assess each construct
for salience, carefully adapt and operationalize defini-
tions for their study (paying special attention to some-
times indistinct boundaries between constructs), discern
the level(s) at which each should be evaluated and
defined (e.g., individuals, teams, units, clinics, medical
centers, regions), decide how to measure and assess, and
be aware of the time points at which measurement and
evaluation occurs while acknowledging the transient
nature of the state of each of these contextual factors. Each
decision and rationale should be documented along with
findings related to each construct.
An example of the importance of discerning the different
levels at which constructs apply is a study conducted by
Van Deusen Lukas and colleagues who found that 'clinic
team knowledge and skills' was associated with effective
implementation [58]. They assessed team knowledge and
skills by surveying individual staff members and then
aggregating to the team level as one unit of analysis in pre-
dictive models. Their final model found significant con-
textual factors at the system (external policy and
incentives), facility (management support), and team
(knowledge and skills) levels. As findings accumulate into
knowledge across study contexts, implementation
researchers will understand more about what works where
and why and be better able to predict implementation
effectiveness across disparate contexts.
The CFIR can be used to guide formative evaluations.
Mendel et al.'s framework of dissemination describes
three phases of evaluation (capacity/needs assessment,
implementation/process evaluation, and outcome/
impact evaluation) in an intervention study or program
evaluation [26] (similar phases are also described by
Stetler et al. [3] as diagnostic analysis, implementation-
and progress-focused evaluations, and interpretive evalu-
ation). Prior to implementation, capacity and needs
assessments are done to identify potential barriers and
facilitators to implement from the perspective of the indi-
viduals and organizations involved in the implementa-
tion. The CFIR provides a list of explicitly defined
constructs for which data can be collected. It is important,
however, that the CFIR not be applied wholesale to every
problem. The long list of constructs, each with their own
level of 'maturity' in definition and operability, can
quickly mire evaluations. Rather, each construct should
be evaluated strategically, in the context of the study or
evaluation, to determine those that will be most fruitful to
study [17] or that are necessary to properly adapt the inter-
vention to the setting. For example, in a current imple-
mentation study, we are assessing the benefits of an
intervention designed to improve blood pressure manage-
ment for patients with diabetes. Before implementation,
we chose salient constructs to guide our capacity/needs
assessment which revealed differences between sites. This
information was used to guide adaptation of the interven-
tion and to develop implementation plans for each site. A
simple example of adaptation is the difference in proto-
cols across study sites for obtaining blood pressure cuffs
for patients.
During implementation, it is important to monitor
progress for unanticipated influences (barriers or facilita-
tors) and progress toward implementation goals. In our
blood pressure management study, baseline findings
from our pre-implementation assessments led us to
closely monitor whether the intervention pharmacists had
ongoing and timely access to the information they needed
for their patient encounters (Access to Information and
Knowledge). We discovered, during the intervention, that
slow-running software at one site was interfering with the
clinical pharmacist's ability to communicate efficiently
with patients during encounters and we were able to facil-
itate a timely solution. Pre-implementation assessments
have allowed us to target collection of real-time data as
implementation progresses to track key implementation
processes, so that we can address problems before they
threaten the intervention's viability. Findings are mapped
to specific CFIR constructs (e.g., access to information and
knowledge)
The third type of evaluation described in Mendel et al.'s
model is outcome and impact evaluation. Post-imple-

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mentation, the CFIR can be used to guide exploration into
the question of what factors influenced implementation
and how implementation influenced performance of the
intervention. For example, the CFIR can be used to assess
changes in the inner setting (e.g., leadership engagement)
as a result of implementation the co-evolution that often
occurs through effective implementation [20]. At all three
evaluation stages, the CFIR provides a framework by
which to understand the dynamic, multi-level, transient
nature of implementation in specific contexts and to
organize and communicate findings across contexts.
At a macro level, the CFIR can be used to organize and
promote synthesis of research findings, studies, and set-
tings [26] using clear and consistent language and termi-
nology, which will further stimulate theory development.
The Consolidated Standards of Reporting Trials (CON-
SORT) Trial Bank Project was developed to do this for
clinical trials by capturing study design, execution details,
and results from randomized clinical trials in a form that
promotes synthesis of results from multiple studies [86].
The recently published Standards for QUality Improve-
ment Reporting Excellence (SQUIRE) guidelines are
designed to promote knowledge-building for implemen-
tation and quality improvement studies by standardizing
how findings from these studies are reported. The SQUIRE
guidelines take into account two essential considerations
missing from the CONSORT guidelines but essential for
implementation studies: 'reflexivity' and setting [15]. The
guidelines suggest that authors specify, '...how elements of
the local care environment considered most likely to
influence change/improvement in the involved site or
sites were identified and characterized' [15]. Constructs
included in the CFIR can be used to explicate those ele-
ments more consistently across studies.
The ultimate judgment of the CFIR's utility and validity
can be discerned by coalescing answers to three questions
over time [12]:
1. Is terminology and language coherent?
2. Does the CFIR promote comparison of results across
contexts and studies over time?
3. Does the CFIR stimulate new theoretical developments?
If answers to all three questions are yes, then we are on the
right path.
Conclusion
The CFIR provides a pragmatic structure for identifying
potential influences on implementation and organizing
findings across studies. It embraces, consolidates, stand-
ardizes, and unifies constructs shown to be associated
with implementation from other published implementa-
tion theories. The CFIR can be used to help guide forma-
tive evaluations of interventions in context and offers an
organizational framework for synthesizing and building
knowledge about what works where, across multiple set-
tings. We propose the CFIR as a means by which to see far;
a road-map for the journey of accumulating an ever more
rich understanding of the complexities of implementa-
tion, and a more predictable means by which to ensure
effective implementations.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
LJD and JCL conceived of the paper. LJD drafted the initial
form and all revisions of this paper. All other authors
(JCL, REK, DCA, SRK, JAA) made significant contributions
to the conceptual framework and read and modified
drafts. All authors read and approved the final manu-
script.
Additional material
Acknowledgements
We gratefully acknowledge thoughtful comments we received on earlier
drafts from Cheryl Stetler, Jane Banaszak-Holl, and Carol VanDeusen
Additional file 1
CFIR Figure and Explanatory Text. This file provides a visual figure
showing the main domains in the CFIR along with explanatory text.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1748-
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Additional file 2
Matrix of Constructs from Models in the Literature to CFIR Con-
structs. A matrix that shows a mapping of constructs from published the-
ories to constructs included in the CFIR.
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Additional file 3
CFIR Constructs with Short Definitions. A 2-page table of CFIR con-
structs with short definitions that can be used as a quick reference.
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5908-4-50-S3.pdf]
Additional file 4
Detailed Rationale for Constructs. Documentation of further references
to support inclusion/definitions of constructs included in the CFIR.
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Lukas. Their comments and dialogue helped strengthen the paper. In addi-
tion, the insightful depth reflected in comments provided by the reviewers
also considerably strengthened the paper.
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