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Table 2 Areas of interaction, overlap, and difference among select CFIR constructs with NPT mechanisms and sub-concepts

From: Understanding implementation context and social processes through integrating Normalization Process Theory (NPT) and the Consolidated Framework for Implementation Research (CFIR)

CFIR constructs

NPT constructs

Interaction of CFIR and NPT

Select case examples

Intervention characteristics

Evidence, strength and quality

Coherence

The sensemaking work people did to see value in using the innovation and come to a shared understanding with others on the benefit of the innovation involved a perception and appraisal of the strength and quality of the evidence.

One physician champion who was keen to bring NSQIP to his site referred to the program as the “alpha and omega of pooled data in the world”.

Relative advantage

Coherence

The perception of a relative advantage involved sensemaking to understand how the innovation differed from previous practices to understand the value and benefits over existing ways of working.

A director making sense of the advantage in using NSQIP to identify areas to focus on Quality Improvement (QI) found the continuous tracking of data through NSQIP was better than previous ways of identifying issues for QI, stating: “it would’ve been manual tracking…if we wanted to take a look at say blood clots or infections…operationally we would like to do that but just sometimes don’t have the time to do it”.

Adaptability

Collective action

The way the innovation can be shaped to different contexts may impact on all aspects of collective action.

An implementation team modified the way data was presented by aggregating data for each surgical specialty. This action mitigated feelings of being individually targeted and promoted positive relational integration.

Outer setting

Patient needs and resources

Coherence and collective action

The sensemaking work people did in using the innovation to identify gaps in patient needs through the NSQIP data led implementation team members to think about relationship building with healthcare providers outside of the surgery unit to address patient needs and resources post-discharge from the hospital.

Sensemaking through the 30-day follow up phone call to patients (a component of NSQIP) and NSQIP data outside of the surgical area (such as emergency room visit data) highlighted a need to improve patient discharge teaching.

A QI Consultant stated: “Patients are coming into our emergency department and not understanding their wound and what they needed to do with it or what to look for…led to the identification of a need for more “education and information sharing with patients on many different levels”.

Cosmopolitanism

Coherence and cognitive participation

Cosmopolitanism points to the key influence of context outside the organization for implementation, a domain that is outside the scope of NPT.

Sensemaking work to understand one’s role in using an innovation and how to use it relied largely on the connection and exchange with external provincial implementation teams.

The data quote below points to the critical role of experienced surgical clinical reviewers outside of the expansion hospital sites in helping new implementation team members understand how to use NSQIP.

A Surgical Clinical Reviewer stated: “So we were able to get quick contact with the SCRs, over on the pilot site hospitals, and just to see how they do things, how they organise their days, what their priorities are, how they balance work demands, and kind of how they saw their program roll out.” [11]

Inner setting

Networks and communications

Coherence, cognitive participation, and collective actions.

Sensemaking to understand role commitments outside of implementation work and ways to overcome time or workload constraints led to collective actions to strengthen communication channels among newly formed implementation teams.

At one site, efforts were made to meet in unconventional spaces to keep each other informed of NSQIP work and to solve challenges as they occurred. This work led to a strong sense of teamness that positively contributed to implementation efforts.

SCR stated: “whether it’s email, text, popping up to the O.R. between cases, they are open to meeting with me and are very responsive in that way" [11].

Culture

Coherence and cognitive participation

Sensemaking work among individuals and teams required a better understanding of values and norms across different professional groups involved. This understanding supported the engagement with professional groups to help with sensemaking around what the innovation is and its value. This work led to legitimation within and between professions to integrate the innovation into routine practices.

After being denied a presence at certain physician meetings, an SCR spent several months building relationships with physicians by helping them to see what his/her role was with NSQIP and how to interpret and use the data. This work led to the re-organizing of relationships as physicians started to see value in the SCR role and NSQIP. The SCR stated: “Now they’re coming to me almost as like a general problem-solver like, Oh what do you think about this or Maybe can you do this project”.

Implementation climate includes six sub-constructs:

Compatibility; relative priority; organizational incentives and rewards; goals and feedback; and learning climate

Coherence, cognitive participation, and collective action

The sensemaking work people engaged in to understand initial reactions to an innovation and the work they did to help others see value in and legitimation for being involved with the innovation led to an alignment between meanings and values leadership and professional groups attached to the innovation (compatibility) and led to improvements in relational integration for the innovation.

The examples below illustrate incompatibility issues between leadership and physicians on the meanings attached to NSQIP. The sensemaking work implementation teams engaged in to understand why some physicians felt threatened by the program led to relational work and thoughtful messaging to help physicians see value in using the program and to reassure them of the intent of using the data.

Operating Room Manager: “the perception at the beginning of it was, they’re looking at my quality, right, like how am I doing and they’re going to use my infection, you know…But (SCR Name) seemed to kind of persevere and, you know, continue to articulate the methodology, to help them understand better what we’re using the information for”.

One Physician Champion involved in a meeting to understand physician concerns about NSQIP learned about their fears such as “the data being left out and missing the curve, you know your numbers are showing you’re not doing a good job [11] and individualized compared to the other guys…you have to spend some time reassuring them”.

One Physician Champion used deliberate language to present NSQIP data as a tool to use as a collective to inform QI initiatives to try to avoid misrepresentations of the data as a way to individually monitor a surgeon’s work: “The whole point of collecting this (referring to data), is so that we, global we, institution, can get better at what we do…I just stress the objectivity of it…These are the numbers that we’re getting. I‘m not pointing the finger at any particular individual or any particular group of individuals or any particular practice.” [11]

Readiness for implementation includes three sub-constructs:

Leadership engagement; available resources; and access to information and knowledge

Coherence and cognitive participation

Leadership engagement involved sensemaking work among Directors and Managers to identify and connect new implementation team roles with existing groups to support integration of the innovation. Availability of resources to support implementation of an innovation can positively or negatively influence sensemaking and legitimation work among individuals and/or groups.

Director: “I participate in the surgeon meetings, add input into kind of priority setting with her (referring the SCR), kind of help influence some of those initiatives in the other units, for her (referring to the SCR), when she gets pushback from leadership around that” [11]

SCR at a different site: “It was very helpful in that she (Manager) quickly incorporated us into our larger team… So our executive directors, all her direct reports…And then also through those connections with the other managers, they’ve invited us to their quality council meetings and that kind of stuff. So that’s beneficial”.

In this example, the lack of material resources to support sensemaking for one Physician put them at risk of not seeing value in contributing to the work (legitimation):

“My problem is that a lot of these meetings are on Skype for Business, and I don’t have access to that. So, I don’t have a computer where I could see any of the PowerPoint presentations. So, I just have to dial in to the audio and figure it out…So for me it’s hard…I’m losing interest as a result because, you know in my hospital doctors don’t have computers” [11].

Characteristics of individuals

Knowledge and beliefs about the intervention

Coherence and cognitive participation

Engaging in sensemaking work to understand what an innovation is about and how it can be used in current practices can positively or negatively change prior knowledge and beliefs and result in the reorganizing or not of relationships to integrate it into practice.

Initially, a physician champion was excited about using NSQIP data to inform QI work. As they learned more about the data they could collect and the data they needed, they realized the innovation was not a good fit. This resulted in low cognitive participation efforts to move implementation forward.

“What was first perceived as a powerful tool became a very vanilla bland look at some variables” [11]

Self-efficacy

Coherence, cognitive participation, and collective action

Belief in one’s capabilities to do the work required sensemaking work to understand what the implementation role required in relation to knowledge and skills. This work preceded actions to address deficits in collective action’s skill set workability to confidently perform an implementation role.

Several SCRs did not have QI work experience before assuming the implementation role. QI learning needs were supported by leadership through enrolment in QI courses at the start of their implementation role and connections between SCRs and QI consultants. Connections between SCRs and QI Consultants led to newly formed working relationships in QI informed by NSQIP data.

Process

Planning

Coherence and cognitive participation

Implementation planning interacts in a cyclical way with individual and collective sensemaking work (coherence) and cognitive participation. It is key for planning to build a shared understanding of the goals and the value of the innovation and to work together to engage key actors to build a community of practice around the innovation. This work informs understandings of how to perform new tasks, what actions, procedures, roles and processes are needed to integrate the work and the innovation into existing workflows.

Creating time for understanding what NSQIP can do to inform improvement in surgical care and how to do the work of NSQIP data collection and of building a community of practice around NSQIP was key to implementation planning. Engagement of leadership and implementation teams within each site and across the province was crucial to help SCRs make sense of their work, how to set up processes, and how to connect to the different professional groups and key actors they needed to regularly interact with to drive NSQIP forward.

Engaging

Coherence, cognitive participation, and collective action

Engaging is related to cognitive participation as both describe the relational work to embed and sustain a new practice into existing workflows. Coherence work intersects with enrolling people in participating and in understanding what their tasks and contributions may be. CFIR highlights the role of a champion, NPT helps understand how a champion is key to helping others with sensemaking (coherence) and recognizing the value in being involved with the innovation.

This complex relational work informs collective action that brings people together in new ways (relational and contextual integration) to work with the innovation.

In this example, the physician champion discussed their understanding of what was behind hesitancies among some physicians about NSQIP. Their narrative reveals the work they did to engage physicians and help them understand the NSQIP data. It also illuminates the leadership style they used to provide guidance and facilitate physician engagement while preserving autonomy as physician groups reorganized themselves to work with data from NSQIP.

Physician Champion:

“They were worried, with the implementation, that people were going to feel that this was monitoring and that there was going to be punitive issues. I am aware of how we disseminate… actually helping people interpret, and that’s where we’re at…I’m trying to tailor it so that each group has their opportunity to deal with it, however they want. So as an example, general surgery…they have a robust well attended monthly business meeting, where they will discuss…trends…But they’ll also talk about upticks in things like infection rates. They may not, again, come up with initiatives about how to address it, but at least it’s part of what they do”.

Reflecting and evaluating

Reflexive monitoring

This CFIR construct refers to using quantitative and qualitative feedback in an ongoing reflection and evaluation of implementation progress and experiences. NPT sub-constructs of reflexive monitoring explore in more detail the individual, collective appraisal of the worth of the new practice, and a systemization of a variety of information, including quantitative and qualitative data, to appraise and potentially redefine and modify the implementation process, or even aspects of the practice.

This example illuminates an individual’s experience appraising the impact of NSQIP implementation work on their clinical and leadership work.

Physician champion:

“If I was going to do it I don’t think…needs two champions. I think (hospital name) needs maybe one champion that has to take a more, give themselves more time. Because that’s my biggest problem…I wouldn’t make it a Chief of Surgery or Anesthesiology, I would try and find a third person because we’ve got so many other things.”