Table 3. Summary of the issues identified in relation to the key domains of the CFIR, and its existing constructs

Domain	Existing CFIR construct¹⁹	Definition within CFIR¹⁹	Emergent issues
I. Intervention characteristics	Evidence strength and quality	The stakeholder’s belief in the quality and validity of the evidence of the intervention having the desired outcome	Evidence for the benefits of PROMs use in primary care
	Relative advantage	The perceived advantage of using a particular intervention versus an alternative or existing solution	PROMs may be used to frame discussions of shared-decision making, justify treatment decisions, support nursing staff
	Adaptability	The degree to which an intervention can be refined to meet the specific needs of the local environment	Ability to be digitalised
	Complexity	The potential disruptiveness and intricacy involved in its implementation	PROMs can take time to complete and to interpret and utilise results
	Design quality	How well the intervention is assembled and presented	PROMs are poorly presented to stakeholders
II. Outer setting	Patient needs and resources	The requirements of patients and the factors that influence how they are met by an organisation	Variation in patient reliability, health literacy, comorbidities
II. Outer setting	External policy and incentives	The strategies that policymakers and commissioners employ to spread the implementation of the intervention, include mandates, guidelines, and financial incentives	Adverse influence of financial incentives, CCG
III. Inner setting	Implementation climate	The capacity for change of an organisation through its attitude to the intervention, their relative priority, and how their use will be supported and rewarded	No pressure for change, compatibility, relative priority
III. Inner setting	Readiness for implementation	The tangible indicators of the decision to implement a particular intervention this includes factors such as access to knowledge, information, and training	GPs lack of awareness of PROMs, no systematic training
IV. Characteristics of individuals	Knowledge and beliefs about the intervention	The attitudes of individual GPs towards any intervention as shaped by their understanding of its use and the value they place on it	Considered a research tool
V. Process	Planning	The engagement of organisations and individuals in the process of change and ensuring an appropriate plan is in place	Lack of coherent approach
V. Process	Engagement	The degree to which relevant individuals are engaged in the process of implementation	Absence of consultation or staff engagement

CCG = clinical commissioning group. CFIR = Consolidated Framework of Implementation Research PROMs = Patient Reported Outcome Measures.