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QUERI – Quality Enhancement Research Initiative

Advancing Implementation Science Lab (AIS) Activity Summary

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Group leaders: Laura Damschroder, MPH,  Julie Lowery, PhD,  Christine Kowalski, MPH

December 9, 2020

Laura Damschroder

Christine Kowalski

Linda Kawentel

Nick Bowersox

Title: AIS Lab Reprise: Real-world research examples in using theory to inform their implementation research projects

The presenters are currently reviewing and categorizing the key highlights from all of the past AIS Lab activities over the past 5 years and how this group has contributed to field of implementation science. We will present real-world research examples that have used theory to inform their implementation research projects and answer the question, what does it take to apply theory in a project? We will discuss theory/framework challenges, strengths, and applications.

August 12, 2020

Teresa M. Damush, PhD

Edward Miech, EdD

Nicholas A. Rattray, Ph.D.

Title: Scoring CFIR constructs and use in cross-case analyses

This presentation by members of the Implementation Core from the PRIS-M QUERI in Indianapolis will highlight the value of using scored constructs from the Consolidated Framework for Implementation Science (CFIR) in cross-case analyses.  It will feature three applied examples and is intended for anyone interested in implementation, quality improvement, mixed-methods research and/or the CFIR framework.

July 8, 2020

Marylou Guihan

Cassie Goedken

Title: Qualitative Evaluation of the Implementation of Carbapenem-resistant Enterobacteriaceae (CRE) Guidelines

The CARRIAGE QUERI presented findings from their qualitative evaluation using CFIR to better understand CRE guideline implementation in VAMCs, “Combating Antimicrobial Resistance through Rapid Implementa­tion of Available Guidelines and Evidence (CARRIAGE) QUERI”

June 10, 2020

Christian Helfrich

Title: “What potentially makes de-implementation different than implementation and why does it matter? Thoughts on theory, outcomes and patient experience”

Dr. Christian Helfrich will lead a discussion about some factors that may distinguish de-implementation from implementation, including discussion of conceptual models, implementation/de-implementation outcomes, and patients’ experiences of de-implementation efforts.

Norton, W.E., Chambers, D.A. Unpacking the complexities of de-implementing inappropriate health interventions. Implementation Sci 15, 2 (2020).

Prusaczyk, B., Swindle, T. & Curran, G. Defining and conceptualizing outcomes for de-implementation: key distinctions from implementation outcomes. Implement Sci Commun 1, 43 (2020).

May 13, 2020

Leah Haverhals, PhD, MA

Chelsea Manheim, LCSW


Chelsea and Leah will present on their application of the CFIR framework to interview data to better assess implementation of the VA Life Sustaining Treatment Decisions Initiative (LSTDI) as part of their work on the Long-Term Care QUERI. Anne Sales, Cari Levy, and Mary Ersek are Co-Investigators on this QUERI project. One arm of this QUERI is to assess implementation of the VA’s mandated changes to documentation of Life Sustaining Treatments and documentation of Goals of Care Conversations through use of the LST template in CPRS.

March 11, 2020

Cathy Battaglia

Borsika Rabin


Cathy Battaglia and Borsika Rabin from the Triple Aim QUERI reflected on their use of RE-AIM and PRISM in their cross-cutting evaluation of their current QUERI program. They provided an overview of the QUERI program and implementation core, reflected on findings, and their lessons learned with a goal of improving the application of these frameworks in the future.

February 12, 2020

Alison Hamilton

Erin Finely

Title:  Complex Adaptive Systems in Implementation Science: New Approaches and Questions for the Field

Erin Finley and Allison Hamilton from the EMPOWER QUERI reflected on their use of theories in their current QUERI program. They described, reflected on findings, and critiqued the theory(s) they have used with a goal of improving application of these theories in the future.

January 8, 2020

Laura Damschroder

Title: Using Configurational Comparative Methods to Synthesize findings across studies using CFIR.

The CFIR was used to identify determinants for seven different implementations of seven different programs within Veterans Health by using configurational comparative methods (CCMs) to identify pathways to successful and to unsuccessful implementation. Three pathways explained 92% of successful implementations. One pathway was the presence of a single facilitating condition: strong positive Leadership Engagement. Two pathways required the combination of multiple conditions: 1) weakly positive Leadership Engagement combined with positive (strong or weak) Access to Knowledge & Information; or 2) positive (strong or weak) Networks & Communication combined with Goals & Feedback and Reflecting & Evaluating. Likewise, three pathways explained 89% of failed implementations. Two pathways required the presence of a single barrier related to: 1) Leadership Engagement; or 2) Implementation Leader or Champion. One additional pathway involved combined barriers related to Access to Knowledge & Information with Networks & Communication.

December 11, 2019

Ashley Choate

Kasey Decosimo

Joshua D'adolf

Title: Lessons learned using the Replicating Effective Programs (REP) Framework in the Function QUERI

In this presentation, we describe the Optimizing Function and Independence QUERI program and our use of Replicating Effective Programs (REP) as a framework for scaling up and spreading 2 Function QUERI clinical programs: STRIDE (Assisted Early Mobility for Hospitalized Veterans) and iHI-FIVES (caregiver skills training). We discuss our experience with REP, as a concept and to the realities of operationalizing REP implementation phases and activities. Using our clinical programs as case studies, we describe the activities, processes, and tools developed to facilitate rollout of these programs at participating sites, as well as program adaptations and key lessons learned.

November 13, 2019

Miriam Bender, PhD, RN

Deborah Lefkowitz, PhD

Title: Clinical Routines as an under-explored yet critical component of context in implementation science

Clinical routines are not included explicitly as a construct in any framework or model including CFIR. Multiple constructs touch on it and could apply or a cluster of constructs, but this may not be adequate. Clinical routines are more than people’s beliefs or readiness: there are people who want something to happen but their clinical routines would have to change dramatically to make it happen, with downside and upside effects and with varying scopes of change.

August 14, 2019

Group discussion

Title: “Triumphs and travails in using and/or advancing theory in our work

This group discussion session was an “Open Mic” time to share our work, learnings, insights, generate dialogue, and use as an opportunity to elicit brief feedback. We discussed stories of triumphs and travails in using and/or advancing theory in our work.

July 10, 2019

Christine P. Kowalski, MPH

Title: Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption

Christine explained the formative evaluation process used to maximize sustainability and adoption of diabetes shared medical appointments implemented at five geographically diverse Veterans Affairs (VA) health systems. Modifiable barriers (actionable findings) and facilitators to implementation were identified using the CFIR framework and adaptations documented—this allowed us to determine which facets to target and act on for each site. As the study progresses, these findings will be compared and correlated to outcome measures. See publication for details: Kowalski, C. P., Veeser, M., & Heisler, M. 2018. Formative evaluation and adaptation of pre-and early implementation of diabetes shared medical appointments to maximize sustainability and adoption. BMC Fam Pract, 19(1), 109.

June 12, 2019

Jane Brock

Amy Huebschmann

Title: Community-Based Care Coordination Improvement in the QIN-QIO Program:  Applying an Implementation Framework

They are using the CFIR to understand a quality improvement initiative that uses community coalitions to facilitate readmissions reduction efforts for a population of Fee-for-Service Medicare beneficiaries defined by geography of residence. They are challenged by identifying the “inner setting,” as the inner setting becomes layered with more than one distinct organization implementing an intervention.  In addition, data comes from individuals aligned with coalition leadership who may be not be directly involved in the organization(s) who

implemented the intervention. They gave concrete examples of this conundrum from interviews with Medicare Quality Improvement Organizations that created community coalitions to develop and drive interventions that were applied in health care partner organizations. Their aim is to describe their approach to inner setting definitions and characteristics for this qualitative analysis, and to invite discussion of alternate approaches that may be useful to address this challenge.

April 10, 2019

Andrea Nevedal

Caitlin Reardon

Title: VA Diffusion of Excellence Evaluation:
Local & System-Level CFIR Application

Andrea and Caitlin have been working with Laura on a QUERI partnered evaluation of the VA’s Diffusion of Excellence (DEI) program that aims to spread best practices systemwide. The DEI includes a Shark Tank where Medical Center Directors bid on promising practices. The winning bidder (aka Shark) is provided support to implement the practice into their facility. The CFIR Is being used to track experiences of local teams in implementing their “Gold Star Practice.” They described preliminary findings of local implementations and asked attendees for ideas on how best to structure expanded evaluation that takes a broader systems and longitudinal perspective. This session highlighted use of CFIR at multiple levels and where gaps may be.

February 13, 2019

Melanie Barwick

Title: The Implementation Game

Dr. Barwick presented - the Implementation Game.

Implementation is a complex process with many moving parts. The Implementation Game (TIG) is a card game that simplifies the process into 5 main components to provide an implementation planning experience for an identified scenario or implementation endeavor. The Implementation Game is relevant to any discipline because the concepts are high level. There is no winner; the goal is either to learn, or to plan, or both. Playing TIG will help you grab that tiger by the tail and ‘win’ at implementation.

January 9, 2019

Claire Cole

Valéry Ridde

Title: “Applying the CFIR for learning & quality improvement scale-up.”

Claire Cole and Valéry Ridde presented on a 5-year study of MNH implementation in Mozambique, “Applying the CFIR for learning & quality improvement scale-up.” Discussed a snapshot of several CFIR global health studies, anthropological lenses, CFIR for community systems, and the possibility of a real-time CFIR tool for managing large-scale.

November 14, 2018

Miriam Bender

Title: “The relationality of intervention, context, and implementation: A prospective case study examining the adoption of an evidence-informed nursing care model.”

Miriam Bender presented on, “The relationality of intervention, context, and implementation: A prospective case study examining the adoption of an evidence-informed nursing care model.” See detailed slides and discussion notes.

October 10, 2018

Laura Damschroder

Julie Lowery

Christine Kowalski

Title: Group discussion, part I trials, travails, and triumphs in applying theory in any stage of your project

The October AIS Lab call was a group discussion of trials, travails, and triumphs in applying theory in any stage of your project(s): data collection, rapid analyses, coding, interpretation, etc. including experiences in using frameworks or models (CFIR or other) and reflections on their utility.

September 10, 2018

Pam Tinc

Title: Applying the Consolidated Framework for implementation research to agricultural safety and health: Barriers, facilitators, and evaluation opportunities

Group discussion of Pam’s recently published paper using the CFIR and provided an update about the remainder of her study / next steps:  Applying the Consolidated Framework for implementation research to agricultural safety and health: Barriers, facilitators, and evaluation opportunities. Pamela J. Tinca,b, Anne Gadomskia,c, Julie A. Sorensena, Lars Weinehallb, Paul Jenkinsa, Kristina Lindvall, Safety Science 107 (2018) 99-108.