This section includes a sampling of tools and frameworks commonly used to drive innovation and improvement in an organization or system. The table below describes these three models and their purpose and users.
These tools provide actionable ways for stakeholders to begin identifying areas for improvement in their health system and determining the best evidence-based practices to drive and sustain improvements in their country. The application of the different components of these tools and frameworks will depend on user needs and context.
IHI Model for improvement
The Institute for Healthcare Improvement (IHI) Model for Improvement is a tool designed to help accelerate improvements in an organization.17 It provides stakeholders or improvement teams with a methodology for understanding the essential elements of system improvement, including the cycle of innovation and ways to develop, test, and implement changes to drive improvement in a system. The model is not intended to replace already existing change models but to drive improvements in different health care processes and ultimately improve outcomes.17 This model is applicable to a wide array of contexts, for example users might leverage the elements of this framework to help policymakers create a strategic plan at the national level or a care team improve a specific service delivery activity at the facility level.
The model includes two parts:
- Three fundamental questions, organized by aim, measures, and changes - these can be answered in any order
- Plan-Do-Study-Act Cycle (PDSA), designed to help users test whether changes result in improvements in real work settings
Aim: What are we trying to accomplish?
Improvement teams should set aims that are time-specific, measurable, and defined to a specific target population or system. Users can find more information on setting aims here.
Measure: How will we know that a change is an improvement?
Improvement teams should select quantitative measures that will determine if a specific change leads to an improvement. Users can find more information on establishing measures here.
Changes: What changes can we make that will result in improvement?
Improvement teams should identify areas for change that are guided by the experiences of those who have worked in the system or have implemented successful improvements. Users can find more information on selecting changes here.
PDSA cycle: Improvement teams use the Plan, Do, Study, Act (PDSA) cycle to test changes as they are being implemented and adjust accordingly. Testing the impact, feasibility, and acceptability of a change involves planning the change, trying it, and studying the impacts of change, then subsequently acting on what is learned from the results. PDSA cycles can and often are repeated multiple times. Users can find more information on testing changes and action-oriented learning here.
Implementing and spreading changes: Implementation involves making a permanent change to a process, such as the way work is done, in a manner that embeds it in the broader organization’s infrastructure and processes, such as through written policies and trainings. Before implementing a change at scale, improvement teams should test a change on a small scale and learn from each iteration through multiple PDSA cycles. After the successful implementation of a change on a broader scale - such as for an entire pilot population or unit - the improvement team can begin to spread the change to other relevant populations. Spread processes should also undergo multiple PDSA cycles to ensure that the change is adaptable and drives predicted improvements in all relevant settings. Users can learn more about enhancing innovation and learning in a system and implementing and spreading changes in the following resources:
Exploration, preparation, implementation, and sustainment (EPIS) framework
The EPIS Framework guides users through the complex process of identifying areas for improvement and through four phases: exploration, preparation, implementation, and sustainment.
Four phases of the implementation process 18 19
- Exploration phase: Potential implementers such as a service system, organization, research group, or other stakeholders, identify what evidence-based practices best address the emerging or existing health needs of the target population. Implementers then decide whether to adopt the identified evidence-based practice(s) depending on their potential to address these needs.
- Preparation phase: Upon deciding to adopt one or more evidence-based practices identified in the exploration phase, implementers identify potential barriers and facilitators of implementation as well as needs for adaptation in preparation for integrating the evidence-based practice into the existing system.
- Implementation phase: The adopted evidence-based practice is integrated into the system. Implementers should ensure that ongoing monitoring is taking place and adjust implementation strategies to support implementation.
- Sustainment phase: The evidence-based practice is ingrained in the system, with ongoing monitoring and/or quality assurance processes and adaptations as necessary, to ensure the evidence-based practice is sustained and health impacts are realized.
Potential factors affecting implementation, such as the innovation characteristics and intra-organizational characteristics, are included in the EPIS framework at each phase at the individual, organization, and system level here. The framework helps stakeholders determine the complex needs of users and the factors driving the successful implementation of evidence-based practices, taking into account the complex dynamics between the different factors affecting implementation. The EPIS framework is a useful tool for designing evidence-based practices or adapting existing ones to operate within the context of a given health system. Stakeholders can find more information on this implementation tool here and learn about the application of this framework to public sector service systems in this research paper.
Consolidated Framework for Implementation Research (CFIR)
The Consolidated Framework for Implementation Research (CFIR) is a tool for identifying implementation factors across contexts and guiding a rapid cycle evaluation of the implementation of evidence-based practices. The CFIR features five major domains: 20
- Intervention characteristics refers to the attributes of an intervention that might affect implementation.
- Inner setting includes the qualities of the implementing organization or system that will potentially influence implementation.
- Outer setting includes features related to the external context or information that may affect implementation.
- Characteristics of the involved individuals refers to the qualities of the individuals involved in implementation.
- Implementation process involves strategies or tactics that may influence implementation.
There are predefined constructs within each of these five domains that may affect the implementation of an intervention.20 21 These constructs can be found here. Each construct analyzes barriers and facilitators to implementing an evidence-based practice in the process of change.
The CFIR approach helps facilitate an understanding of how an evidence-based practice is implemented and what constructs support or pose barriers to the process of change. CFIR can be conducted at any stage of the implementation process. CFIR can help produce actionable findings intended to improve the implementation of interventions to achieve a better outcome, including what adjustments and refinements need to be made to an intervention. 20 21