Operationalizing the Consolidated Framework for Implementation - - PowerPoint PPT Presentation

Operationalizing the Consolidated Framework for Implementation Research into a Mixed Methods Measure: The CFIR Index

MEHRET ASSEFA AND MARK MCGOVERN CENTER FOR BEHAVIORAL HEALTH SERVICES AND IMPLEMENTATION RESEARCH STANFORD UNIVERSITY SCHOOL OF MEDICINE

NIDA 5R01DA037222; NIDA R01DA027650; NIDA R01DA015186

Background

CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH (CFIR)

 As an emerging science, implementation research needs

• bjective and standardized measures to advance

 Tabak et al (2012) identified Damschroder et al’s (2009)

Consolidated Framework for Implementation Research (CFIR) among the most promising for operationalization

 To date, the CFIR has primarily been formative and

qualitative in methodology (Kirk et al, 2016)

 We designed and operationalized a quantitative measure:

The CFIR Index

Background

CFIR Index vs CFIR

 Quantitative measure

 More reliably & consistently document contextual factors

associated with successful/unsuccessful implementations

 Eliminated 5th dimension – Process

 Focuses on aspects associated with the planning and process of

the implementation strategy

 Eliminated Design & Packaging Item  Renamed all dimensions & some items

 E.g., Changed Cosmopolitanism item to Network Connectivity

Methods

CFIR Index

 Quantitative measure of contextual barriers and

facilitators to the implementation process

 Consists of 30 items across 4 dimensions:

 Perceptions of the Intervention (7 items)  Perceptions of the System and Community (4 items)  Perceptions of the Program (14 items)  Perceptions of the Clinicians Who Will Use the Intervention (5 items)

 Items are rated on a 5-point Likert-type scale from

1- Barrier to 3-Neutral to 5-Faciliator

Methods

CFIR Index V2.0

Methods

CFIR Index

Data to complete the CFIR Index were

gathered during a half-day onsite visit to an agency and triangulating information:

 Key informant interviews  Observation  Document review

Methods

NIDA-funded Studies

 CFIR Index data were obtained across three separate

NIDA-funded studies and three EPIS phases:

 Exploration: one organization’s implementation of a multi-

component behavioral therapy for youth with SUD

 Implementation: forty-nine organizations’ implementation

• f integrated services for co-occurring SU and MH disorders

 Sustainment: seven organizations’ sustainment of an

integrated cognitive therapy for comorbid PTSD and SUD, and an individual addiction counseling approach

Psychometrics: Reliability & Validity

Sustainment and Preparation Phase Studies

 Reliability of the measure was supported by

estimates of inter-rater agreement and internal consistency

 Predictive validity was supported by differentiation

• f high versus low implementation sites

 Discriminant validity was supported by observed

distinctions between the two implemented practices

CFIR Dimension Scores at Baseline

Implementation Phase Study

3.61 3.66 3.73 4.06 3.40 3.26 3.51 3.72 1 2 3 4 5

Perceptions of the Intervention Perceptions of the System and Community Perceptions of the Program Perceptions of the Clinicians

CFIR Index Score NIATx Waitlist

Top Barriers and Facilitators

Implementation Phase Study

14.3% 16.3% 22.4% 79.6% 81.6% 83.7% 0% 50% 100%

Complexity, Resource Availability, and Network Communications Costs Extenal Policy and Incentives Leadership Engagement Clinician Self-Efficacy Relative Priority Facilitators

Bar

Facilitators (CFIR Score ≥4) Barriers (CFIR Score ≤2)

Correlation Between DDCAT and CFIR Dimension Scores at Baseline

Implementation Phase Study DDCAT CFIR Index

Perceptions

• f the

Intervention Perceptions of the System and Community Perceptions

• f the

Program Perceptions of the Clinicians Program Structure

0.229 0.332* 0.371* 0.278

Program Milieu

0.177 0.176 0.393** 0.218

Clinical Process: Assessment

0.244 0.259 0.432** 0.343*

Clinical Process: Treatment

0.247 0.191 0.414** 0.302*

Continuity of Care

0.118 0.058 0.306* 0.125

Staffing

0.263 0.292* 0.453** 0.329*

Training

0.253 0.307* 0.354* 0.278

*p≤0.05 **p≤0.01 (2-tailed)

Do CFIR Scores Predict Positive Change in DDCAT Scores from Baseline to One Year Follow-up?

Implementation Phase Study

 Total Sample

 Tension for Change r = +.40; Organizational Incentives r = -.35

 NIATx Study Arm

 Implementation Climate r = +.54; Tension for Change r = +.54;

Complexity r = +.49; Relative Priority r = +.48; Peer Pressure r = +.47; Evidence Strength and Quality r = +.44  Waitlist Study Arm

 No statistically significant relationships

Conclusion

Implications for D&I Research

 CFIR Index data may be useful to tailor strategies

when addressing barriers with providers

 CFIR Index appears promising as a standardized

and replicable measure of contextual mediators and moderators of a D&I project

 Standardized measures are critical to the

evolution of implementation science

Conclusion

Next Steps

Continued refinement of the measure

(presently version 3.0)

Further application in designed tailoring of

implementation strategies to study mechanisms of action

Thank You

MEHRET ASSEFA & MARK MCGOVERN CENTER FOR BEHAVIORAL HEALTH SERVICES AND IMPLEMENTATION RESEARCH DIVISION OF PUBLIC MENTAL HEALTH AND POPULATION SCIENCES DEPARTMENT OF PSYCHIATRY & BEHAVIORAL SCIENCES STANFORD UNIVERSITY SCHOOL OF MEDICINE 1520 PAGE MILL ROAD PALO ALTO, CALIFORNIA 94304 mpmcg@stanford.edu mehret.assefa@stanford.edu