Contextual Frameworks for Research on the Implementation of Complex System Interventions

Objectives This report presents the adaptation of the Consolidated Framework for Implementation Research (CFIR) to three complex system interventions involving (1) process redesign for improved efficiency and reduced costs (PR); (2) patient-centered medical homes (PCMH); and (3) care transitions. The purpose of the adapted frameworks— the PR Framework, PCMH Framework, and Care Transitions Framework—is to guide research on how, why, and where these interventions succeed or fail to achieve intended outcomes. Data sources MEDLINE™. Additional studies were identified through the gray literature and technical experts. Methods The adaptation was informed by the findings from a scan of selected literature on PR, PCMH, and care transitions, which included articles in MEDLINE, the published and gray literature, and recommendations of content experts at the Agency for Healthcare Research and Quality. A Technical Expert Panel (TEP) for each topic reviewed the draft of the contextual frameworks and provided input on the structure and content through a series of 2-hour calls. In addition, the PR and PCMH Frameworks were reviewed by two separate TEPs for usability. In total, five TEPs were convened for this work. Results While retaining much of the CFIR's original structure and most of its original concepts, the revised frameworks address distinctive features of each of the three interventions. We added concepts relevant to each topic area, and more explicitly addressed the iterative and interactive nature of complex system change. We also modified nearly all the definitions of the CFIR constructs to incorporate terminology and examples tailored to the specific interventions. Two new domains were added to each of the frameworks—one for intermediary outcomes related to the implementation and one for outcomes of the interventions themselves. Several CFIR domains and constructs were renamed to be more resonant with the intervention's research target group. None of the original CFIR constructs were dropped, but several dozen new constructs were added across the three new frameworks. As these were iterative products, with initial PR and PCMH Frameworks informing the Care Transitions Framework, many of these new constructs overlap across the frameworks. Conclusions These contextual frameworks provide a foundational taxonomy and conceptualization of key implementation constructs that researchers can use across studies to enhance their comparability and synthesis, thereby better informing the generalizability and replicability of specific interventions. In adapting the CFIR for complex system interventions, we thought it critical to include input from both research and practice stakeholders to ensure that the content is understandable and applicable to the intervention strategy of interest.