Relational Connections

There are high quality formal and informal relationships, networks, and teams within and across Inner Setting boundaries (e.g., structural, professional).

The original CFIR elaborated on this construct by recognizing that research on organizational change has moved beyond simplified measures of Inner Setting structure, and increasingly embraces the complex role that networks have on implementation of innovations (L. A. Fitzgerald & van Eijnatten, 2002). This construct includes Greenhalgh’s intraorganizational networks (Greenhalgh, Robert, et al., 2004). Connections between individuals, units, services, and hierarchies may be strong or weak, formal or informal, tangible or intangible, visible or invisible. There is much interplay between formal structure, informal networks, and communications (see Communications). Assessments may be informed by social networking (Scott, 2000), complexity (Burnes, 2005; L. A. Fitzgerald & van Eijnatten, 2002), or other theories, or a more inductive, grounded approach can be used. Social capital describes the quality and the extent of relationships and includes dimensions of shared vision and information sharing. One component of social capital is the internal bonding of individuals within the Inner Setting (Greenhalgh, Robert, et al., 2004). Complexity theory posits that relationships between individuals may be more important than individual attributes (Plsek & Wilson, 2001), and building these relationships can positively influence implementation (Safran et al., 2006).

More recent literature has acknowledged the key role of teams (Dy et al., 2015; Means et al., 2020) and how ideally, relationships evolve to build a sense of ‘teamness’ or ‘community’ that may contribute to implementation outcomes (Edmondson, 2012; Edmondson et al., 2001). The original CFIR went on to highlight teamwork as an essential “core property” for successful implementation of quality improvement initiatives (Ferlie & Shortell, 2001)(page 287). The more stable teams are (members are able to be with the team for an adequate period of time; low turnover), the more likely implementation will be successful (Edmondson et al., 2001). Teamness is a state and is an essential core property for successful implementation (Ferlie & Shortell, 2001). More recently, Edmondson has described the role of increasingly dynamic teams working in complex systems like healthcare (Edmondson, 2012) (see also, Implementation Process: Teaming).

Greenhalgh et al. cite strong or moderate influence of at least a partial role of Inner Setting networks and internal boundary spanning on implementation (Greenhalgh, Robert, et al., 2004). Strong horizontal and informal networks have a positive relationship with adoption; e.g., physicians are influenced by the spreading of information through their peers (Greenhalgh, Robert, et al., 2004). Coordination across departments and specialties is essential for effective implementation to attenuate the “complex web of sources of power and covert and overt sources of influence” that all contribute to individual decisions about whether to cooperate (Feldstein & Glasgow, 2008 p233). A core principle of complexity theories leads to the idea that the actions of individuals and units affect implementation, positively or negatively, in predicted and unpredicted ways (L. A. Fitzgerald, 2002). Integration to bridge traditional intra-organizational boundaries among individual units is one of five critical elements for driving transformation in patient care (VanDeusen Lukas et al., 2007). Physicians and nurses may struggle with routine (and role) changes that require coordination of activities and sharing of information across professions or units (Klein et al., 2001).

Qualitative coding guidelines that are aligned with the Updated CFIR will be added in the future.

Inclusion Criteria

Include statements about general networking and relationships in the organization, such as descriptions of meetings, email groups, or other methods of keeping people connected and statements related to team formation, quality, and functioning.

  • “We worked with prosthetics and physical therapy to get this going.”
  • “The people in prosthetics wouldn’t order the supplies we needed…they care more about rules than helping patients.”
  • “I have a great relationship with my boss…she supports me in getting this by asking me status and we have regular meetings.” Note: May double-code this with Roles/Leadership+Motivation in the Individuals Domain.
  • “We hardly knew each other in the beginning but now we are a real team – we even go out to dinner sometimes.”

Exclusion Criteria

Exclude statements related to implementation leaders’ and users’ access to knowledge and information regarding using the program, i.e. training on the mechanics of the program and code to Access to Knowledge & Information.

Exclude statements related to engagement strategies and outcomes, e.g., how Deliverers became engaged with the innovation and what their role is in implementation, and code to Engaging: Deliverers in the Implementation Process Domain.

Exclude descriptions of outside group memberships and networking done outside the organization and code to Partnerships & Connections in the Outer Setting Domain.

Regarding quantitative measurement of this construct: In a systematic review of quantitative measures related to implementation, Dorsey et al. identified 29 measures (Dorsey et al., 2021). These measures relate to both Relational Connections and Communications in the updated CFIR. Using PAPERS criteria of measurement quality with an aggregate scale ranging from -9 to +36 (Lewis, Mettert, Stanick, et al., 2021), five (17.24%) of the measures could not be scored. The Texas Christian University Organizational Readiness for Change (Lehman et al., 2002) achieved the highest score of 10. Results indicate the need for continued development of high-quality measures.

As we become aware of measures, we will post them here. Please contact us with updates.

Burnes, B. (2005). Complexity theories and organizational change. International Journal of Management Reviews, 7(2), 73–90.

Dy, S. M., Ashok, M., Wines, R. C., & Rojas Smith, L. (2015). A Framework to Guide Implementation Research for Care Transitions Interventions: Journal for Healthcare Quality, 37(1), 41–54.

Dorsey, C. N., Mettert, K. D., Puspitasari, A. J., Damschroder, L. J., & Lewis, C. C. (2021). A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence. Implementation Research and Practice, 2, 263348952110024.

Edmondson, A. C. (2002). The Local and Variegated Nature of Learning in Organizations: A Group-Level Perspective. Organization Science, 13(2), 128–146.

Edmondson, A. C. (2012). Teaming: How organizations learn, innovate, and compete in the knowledge economy. Jossey-Bass.

Feldstein, A. C., & Glasgow, R. E. (2008). A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf, 34(4), 228–243.

Ferlie, E. B., & Shortell, S. M. (2001). Improving the quality of health care in the United Kingdom and the United States: A framework for change. Milbank Q, 79(2), 281–315.

Fitzgerald, L. A., & van Eijnatten, F. M. (2002). Reflections: Chaos in organizational change. Journal of Organizational Change Management, 15(4), 402–411.

Fitzgerald, L. A. (2002). Chaos: The lens that transcends. Journal of Organizational Change Management, 15(4), 339–358.

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: Systematic review and recommendations. Milbank Q, 82(4), 581–629.

Klein, K. J., Conn, A. B., & Sorra, J. S. (2001). Implementing computerized technology: An organizational analysis. Journal of Applied Psychology, 86(5), 811–824.

Leeman, J., Baquero, B., Bender, M., Choy-Brown, M., Ko, L. K., Nilsen, P., Wangen, M., & Birken, S. A. (2019). Advancing the use of organization theory in implementation science. Preventive Medicine, 129, 105832.

Lewis, C. C., Mettert, K. D., Stanick, C. F., Halko, H. M., Nolen, E. A., Powell, B. J., & Weiner, B. J. (2021). The psychometric and pragmatic evidence rating scale (PAPERS) for measure development and evaluation. Implementation Research and Practice, 2, 263348952110373.

Means, A. R., Kemp, C. G., Gwayi-Chore, M.-C., Gimbel, S., Soi, C., Sherr, K., Wagenaar, B. H., Wasserheit, J. N., & Weiner, B. J. (2020). Evaluating and optimizing the consolidated framework for implementation research (CFIR) for use in low- and middle-income countries: A systematic review. Implementation Science, 15(1), 1–19. Plsek, P. E., & Wilson, T. (2001). Complexity, leadership, and management in healthcare organisations. Bmj, 323(7315), 746–749.

Safran, D. G., Miller, W., & Beckman, H. (2006). Organizational dimensions of relationship-centered care. Theory, evidence, and practice. J Gen Intern Med, 21 Suppl 1, S9-15.

Scott, J. (2000). Social Network Analysis: A Handbook (2nd ed.). Sage Publications.

VanDeusen Lukas, C., Holmes, S. K., Cohen, A. B., Restuccia, J., Cramer, I. E., Shwartz, M., & Charns, M. P. (2007). Transformational change in health care systems: An organizational model. Health Care Management Review, 32(4), 309–320.