Innovative physical therapy practice: a qualitative verification of factors that support diffusion of innovation in outpatient physical therapy practice

Figures & data

Figure 1 Chronology of the study design.

Abbreviation: DCE, Director of Clinical Education.

Table 1 The innovation

CFIR constructs	Level of agreement	CFIR definition^Citation23
Innovation source	N	Perception by the members of the organization about whether the innovation is externally or internally developed
Evidence strength and quality	N	Organization members’ perceptions of the quality and reliability of the evidence that the innovation will produce the desired outcomes
Relative advantage (observability)	+	Organization members’ belief in the advantage of the innovation as an alternative to the status quo
Adaptability (reinvention)	+	The degree that the innovation can be adjusted to improve fit to the organization
Trialability	++	The degree that the innovation can be trialed or implemented in smaller scale or steps
Complexity	+	The degree of difficulty that the innovation entails including the number of steps and the number of choices that the innovation involves
Design quality and packaging	+	Effectiveness of the presentation of the innovation to organization members
Cost	N	Resources required for innovation implementation including money, time, training, and productivity risks

Notes: +, agreement; ++, strong agreement; N, neutral/not confirmed. Adapted from Damschroder L, Aron D, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.²³

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Table 2 Characteristics of individuals

CFIR constructs	Level of alignment	CFIR definition^Citation23
Knowledge and beliefs about the innovation	+	Attitudes and understanding of the innovation, in particular, command of the knowledge and skills the innovation requires
Self-efficacy	++	Belief in capability to be successful in implementation steps
Individual stage of change	+	Phase of the innovation use by the individual ranging from awareness, decision to change, adoption, confirmation; individual orientation to acceptance of change
Individual identification with organization	++	Perceived relationship, alignment and level of commitment to the organization
Other personal attributes	++	Other characteristics of individuals in the specific organizational context including career aspirations

Notes: Bold text indicates expanded definition. +, agreement; ++, strong agreement. Adapted from Damschroder L, Aron D, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.²³

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Figure 2 Distribution of self-identified adoption.

Abbreviation: PT, physical therapist.

Table 3 The inner setting

CFIR constructs	Level of alignment	CFIR definition^Citation23
Structural characteristics	N	The organization’s size, age, and level of differentiation
Networks and communications	++	The nature and quality of information and formal communications and effectiveness of networks to convey information
Culture	++	Values, norms, traditions, and assumptions within an organization
Implementation climate (absorptive capacity for new knowledge)		The level of receptivity of innovation among organization members and the degree that innovation within the organization is expected and rewarded
Tension for change	+	The degree that members find the innovation necessary and perceive the alternative, status quo, as untenable
Compatibility	++	The innovation’s alignment with the organization’s values and established systems and workflow
Relative priority	N	Organization members’ shared perception of the importance of innovation. Negative effect of cumulative changes
Organizational incentives and rewards	N	Tangible – raises, promotion, and award, and intangible – prestige, status, gained by members who adopt the innovation. Conversely, the impact of potential disincentives or penalty/loss for members or organizations who fail in implementation
Goals and feedback	+	The extent that the objectives of the innovation are communicated and that implementation feedback aligns with stated goals. Need for small steps. Incremental, specific, attainable steps coupled with leadership commitment
Learning climate	++	The organization’s attributes to support learning, including a) leaders who express fallibility; b) collective efforts valued; c) psychological safety among members; d) time to make/share meaning through reflection; e) members who are not constrained by failure. Learning in organization is a “core property”
Readiness for implementation: (receptive context for change)		Tangible and specific indicators of the organization’s commitment to implement an innovation
Leadership engagement	++	Commitment, involvement, and accountability of the organization’s leaders and managers
Available resources	N	Resources dedicated to successful implementation of an innovation, money, time, training, and space. Resources serve as mediator or proxy of management support
Access to knowledge and information	+	Members’ access to and ease of understanding information about the innovation and its implementation

Notes: Bold text indicates expanded definition. +, agreement; ++, strong agreement; N, neutral/not confirmed. Adapted from Damschroder L, Aron D, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.²³

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Table 4 The outer setting

CFIR constructs	Level of alignment	CFIR definition^Citation23
Patient’s needs and resources	++	The extent that the organization’s ability to meet its patients’ needs is understood and valued by the organization’s members
Cosmopolitanism	+	The extent of the organization’s networks to external influences and competing organizations
Peer pressure	N	The level of innovation modeled by organization peers that compels imitation or improvement
External policies and incentives	++	Requirements, regulations, opportunities, or threats originating outside the organization that require reaction

Notes: +, agreement; ++, strong agreement; N, neutral/not confirmed. Adapted from Damschroder L, Aron D, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.²³

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Table 5 The process

CFIR constructs	Level of alignment	CFIR definition^Citation23
Planning	+	The level and quality of preparation for the implementation of an innovation
Engaging		Deliberate strategies including education, modeling, and training, to involve organization members in the implementation of an innovation
Opinion leader	++	Respected member within an organization who is influential in changing attitudes and behaviors. Integrity and prudence, attentive to group norms and builds credibility by evaluating innovation against norms
Formally appointed internal implementation leaders	N	Individual appointed to implement an innovation
Champions	N	Individual who is dedicated to the innovation by advocating for success and challenging resistance
External change agents	+	Individual outside the organization who influences or facilitates the innovation implementation
Executing	+	Completing the planned implementation
Reflecting and evaluating	++	Use of feedback to appraise the level and quality of the innovation implementation

Notes: Bold text indicates expanded definition. +, agreement; ++, strong agreement; N, neutral/not confirmed. Adapted from Damschroder L, Aron D, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.²³

Abbreviation: CFIR, Consolidated Framework for Implementation Research.

Figure 3 Communication networks.

Notes: Circle size represents individual level of influence. Line width indicates strength of tie.

Figure S1 Diffusion of Innovation Curve.

Table S1 Member check feedback survey (indicate the degree that the following study findings seem true)

Findings statement	Very accurate	Somewhat accurate	Somewhat inaccurate	Very inaccurate
Change tends to be introduced by clinic members who are influenced by information sources outside the clinic
Physical therapists (PTs) in this clinic rely on comfortable networks of communication to gain information and make meaning of changes
The clinic has a general tolerance of change and is represented by those who identify as progressive and innovative
For change to be accepted in this clinic, it has to seem compatible with the current clinic values and goals
PTs in this clinic choose experimentation over mandates in the process of implementing new things
PTs in this clinic need tangible proof that change is needed and working
Any changes in this clinic must be grounded in the patient-centered care that we provide
Our clinic is always positioned for the next opportunity or to respond to the next threat
Our clinic’s ability to change and survive makes the relationships among staff stronger
Comments:
1. Does a shared philosophy of care create a culture that makes changes easier or harder?
2. In a clinic with staff who share a philosophy of care, how are new ideas best cultivated?
3. To what degree does innovation flow both ways, with introduction of change from either within the clinic or outside?
4. How does the process of change differ depending on where the idea comes from?

DamschroderLAronDKeithREKirshSRAlexanderJALoweryJCFostering implementation of health services research findings into practice: a consolidated framework for advancing implementation scienceImplement Sci2009415019664226

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