Organization of tasks and responsibilities within and between individuals and teams, and general staffing levels, support functional performance of the Inner Setting.
A multi-country analysis of contextual features by Squires et al. includes a construct specific to work structures (Squires et al., 2019), described as the “arrangement of tasks, responsibilities, and resources within and between the various teams in […] settings, and delegation of tasks among supervisors and subordinates.” This includes “the arrangement of schedules, shifts, and on-call duties, the order of work tasks and procedures, and the management of workloads (Squires et al., 2019).” General staffing (e.g., chronic understaffing) and turnover are included in this construct because of their significant effects on task allocation. General staffing levels indicate level of scarce (relatively limited) or slack (relatively abundant) resources in terms of time availability to take on new implementation. Slack resources are thought to promote absorptive capacity (a potential antecedent assessment related to implementation readiness – refer to the CFIR Outcomes Addendum for more detail (Damschroder et al., 2022)) because of the increased ability to absorb failure (Damanpour, 1991; Singh & Lumsden, 1990) or take on new initiatives. However, in a meta-analysis, slack resources were not a significant influence, perhaps because of the lack of distinction between different types of slack resources (Damanpour, 1991). This is differentiated from time allocations specifically for people to participate in implementation or delivery of the innovation (see Individuals: Characteristics: Opportunity).
The original CFIR elaborated on this by describing social architecture: how large numbers of people are clustered into smaller groups and differentiated, and how the independent actions of these differentiated groups are coordinated for functional performance (Thompson et al., 2003). When teams are stable (i.e., members remain with the team for an adequate period of time; there is low turnover), implementation is more likely to be successful (Edmondson et al., 2001). Functional differentiation is the internal division of labor where coalitions of professionals are formed into differentiated units. The number of units/departments represents diversity of knowledge in an organization. The degree of specialization (the number of different occupational types or specialties in a setting) can have a positive relationship with implementing change when the knowledge base is increased (Kimberly & Evanisko, 1981). Related to social architecture, the number of departments that participate in decision-making is positively associated with effective implementation (Aiken et al., 1980; Baldridge & Burnham, 1975; Damanpour, 1991; Greenhalgh, Robert, et al., 2004); centralization (the dispersion or concentration of decision-making autonomy) has mixed effects depending on the study (Damanpour, 1991) and the stage of innovation (initial v. implementation stage) (Dewar & Dutton, 1986). In a recent study in the Veterans Health Administration, centralized decision-making and the associated bureaucratic structures delayed implementation completion (Nevedal et al., 2020).The degree of vertical integration (the number of hierarchical levels in departments or units) has a mixed relationship with implementation (Aiken et al., 1980; Damanpour, 1991; Hull et al., 2019). Administrative intensity (the ratio of managers to total employees) has a positive relationship with implementation (Damanpour, 1991). Clear role definitions (e.g., physician and non-physician roles) positively influences implementation (Bodenheimer, 2002; Bodenheimer et al., 2002). The PARHiS framework asserts that clearly defined physical, social, cultural, structural, and system boundaries contributes to innovation uptake (A. Kitson et al., 1998; Rycroft-Malone, Kitson, et al., 2002).
Qualitative coding guidelines that are aligned with the Updated CFIR will be added in the future.
Regarding quantitative measurement of this construct: In a systematic review of quantitative measures related to implementation, Dorsey et al. identified 13 measures (Dorsey et al., 2021). Using PAPERS criteria of measurement quality with an aggregate scale ranging from -9 to +36 (Lewis, Mettert, Stanick, et al., 2021), four (30.77%) of the measures could not be scored and scores for the remaining measures ranged from -2 to +6. Themes within the measures included objective descriptors of work infrastructure. 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.
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