Table 1.

Integration of research methods, IR frameworks, and implementation strategies by phase of INSPIRE.

INSPIRE actionResearch methods utilizedIR frameworksImplementation strategies
Hub1. Define problem situation with stakeholdersSSMCFIR-1: intervention sourceBuild buy-in (involve existing governance structures, ID champions)
2. Launch the projectCFIR-5: engagingDevelop relationships (build coalitions, resource-sharing agreements, formal commitments, academic partnerships)
Phase I3. Develop mental models of the systemAIIMCFIR-2/HSF: defining structural characteristics, networks, and communicationsGather information (needs assessment, readiness to change)
4. Establish narrative and stakeholder perceptions of the systemSAST stage 1 with key informant interviews and FGDsCFIR-2: culture and implementation climateInvolve patient/consumers and family members
5. Make the system visibleKAP surveysCFIR-3: patient needs and resourcesAudit current system behavior
Audits of current system outcomesCFIR-3: external policies and incentivesCapture and share local knowledge
Pathway analysis visually represented by flow charts and swim-lane diagramsCFIR-4: knowledge and beliefs about the intervention
CFIR-4: understand self-efficacy, individual stage of change and other attributes
Phase II6. Engage stakeholders in group model buildingSAST stage 2 – DWsCFIR-1: review characteristics of the intervention and options (evidence strength and quality, relative advantage, complexity, cost) and assess adaptability and trialability of alternativesAssess readiness and identify barriers
7. Share, test, revise system/process mapsDialectic debate and group model building (facilitated with goal to balance desirability and feasibility guided by reflection on implementation outcomes such as feasibility, cost, acceptability, sustainability, etc.)CFIR-3: assess cosmopolitanism, peer pressure, influence of external policies/incentivesGet feedback from audit of current system behavior
8. Define and localize system behaviors contributing to problem situationScenario analysisCFIR-4: assess KAB about intervention optionsPurposefully reexamine the intervention
9. Find leverage for changeCFIR-4: group-level stage of changeTailor strategies to overcome barriers and honor preferences
Model and simulate change
Conduct local consensus discussions
Distribute educational materials and conduct educational meetings
Make training/education dynamic and participatory
Inform local opinion leaders
Create a learning collaborative
Consider restructuring strategies as leverage opportunities
Consider financing strategies as leverage opportunities
Mandate change
Phase III10. Stakeholder-designed implementation planWork group SSM with research team facilitationCFIR-1: design qualityDevelop a formal implementation blueprint
11. Infrastructure modifications, training, dissemination plan developmentCFIR-1: complexityTailor strategies to overcome barriers and honor preferences
12. Implement changesCFIR-5: planningStage implementation scale-up
CFIR-5: executingInvolve patients/consumers and family members
Recruit, designate, and train for leadership
Obtain formal commitments
Develop effective educational materials relevant to mandated change
Develop a glossary of implementation (including new models)
Distribute educational materials
Conduct ongoing, dynamic training
Conduct educational outreach visits
Use train-the-trainer strategies
Provide ongoing consultation
Place new interventions on fee for service lists/formularies
Develop supply chain management
Revise professional roles
Create new clinical teams
Change services sites
Change equipment
Change records systems
Develop and organize quality monitoring systems
Develop tools for quality monitoring
Use advisory boards and work groups
Conduct cyclical tests of change
Create or change credentialing and/or licensure standards
Phase IV13. Ongoing M&E using stakeholder-defined implementation outcome metricsM&E for primary implementation outcomesRE-AIMProvide ongoing consultation
14. Share M&E with stakeholder groupSAST with KII and FGDCFIR-5: reflecting and evaluatingSustain a learning collaborative
15. Reinitiate INSPIRE cycle where indicated by identification and localization of new or unresolved problem situationDWsUse mass media to increase reach (only after system behavior is stabilized postimplementation)
Use advisory boards and working groups
Organize clinical implementation team meetings
  • Abbreviations: AIIM, alignment, influence, and interest matrix; DW, design workshop; FGD, focus group discussions; HSF, health systems framework; KAB, knowledge, attitudes, and beliefs; KAP, knowledge, attitudes, and practices; KII, key informant interview; SAST, strategic assumption surfacing and testing.