Work Infrastructure

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.

Aiken, M., Bacharach, S. B., & French, J. L. (1980). Organizational Structure, Work Process, and Proposal Making in Administrative Bureaucracies. Academy of Management Journal, 23(4), 631–652.

Baldridge, J. V., & Burnham, R. A. (1975). Organizational Innovation: Individual, Organizational, and Environmental Impacts. Administrative Science Quarterly, 20(2), 165.

Bodenheimer, T., & Sinsky, C. (2014). From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. The Annals of Family Medicine, 12(6), 573–576.

Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving Primary Care for Patients With Chronic Illness: The Chronic Care Model, Part 2. JAMA, 288(15), 1909.

Damanpour, F. (1991). Organizational Innovation: A Meta-Analysis of Effects of Determinants and Moderators. The Academy of Management Journal, 34(3), 555–590.

Damschroder, L. J., Reardon, C. M., Opra Widerquist, M. A., & Lowery, J. (2022). Conceptualizing outcomes for use with the Consolidated Framework for Implementation Research (CFIR): The CFIR Outcomes Addendum. Implementation Science, 17(1), 7.

Dewar, R. D., & Dutton, J. E. (1986). The Adoption of Radical and Incremental Innovations: An Empirical Analysis. Management Science, 32(11), 1422–1433.

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., Bohmer, R. M., & Pisana, G. P. (2001). Disrupted routines: Team learning and new technology implementation in hospitals. Administrative Science Quarterly, 46(4), 685–716.

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.

Hull, L., Goulding, L., Khadjesari, Z., Davis, R., Healey, A., Bakolis, I., & Sevdalis, N. (2019). Designing high-quality implementation research: Development, application, feasibility and preliminary evaluation of the implementation science research  development (ImpRes) tool and guide. Implementation Science : IS, 14(1), 80.

Kimberly, J. R., & Evanisko, M. J. (1981). Organizational innovation: The influence of individual, organizational, and contextual factors on hospital adoption of technological and administrative innovations. Academy of Management Journal. Academy of Management, 24(4), 689–713.

Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence based practice: A conceptual framework. Quality and Safety in Health Care, 7(3), 149–158.

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.

Nevedal, A. L., Reardon, C. M., Jackson, G. L., Cutrona, S. L., White, B., Gifford, A. L., Orvek, E., DeLaughter, K., White, L., King, H. A., Henderson, B., Vega, R., & Damschroder, L. (2020). Implementation and sustainment of diverse practices in a large integrated health system: A mixed methods study. Implementation Science Communications, 1(1), 61.

Rycroft-Malone, J., Kitson, G., Harvey, B., McCormack, K., Seers, A. T., & C. Estabrooks. (2002). Ingredients for change: Revisiting a conceptual framework. (Viewpoint). Quality and Safety in Health Care, 11(2), 174–180.

Singh, J. V., & Lumsden, C. J. (1990). Theory and Research in Organizational Ecology. Annual Review of Sociology, 16, 161–195. JSTOR.

Thompson, J., Scott, W., & Zald, M. (2003). Organizations in Action: Social Science Bases of Administrative Theory. Transaction Publishers.

Squires, J. E., Aloisio, L. D., Grimshaw, J. M., Bashir, K., Dorrance, K., Coughlin, M., Hutchinson, A. M., Francis, J., Michie, S., Sales, A., Brehaut, J., Curran, J., Ivers, N., Lavis, J., Noseworthy, T., Vine, J., Hillmer, M., & Graham, I. D. (2019). Attributes of context relevant to healthcare professionals’ use of research evidence in clinical practice: A multi-study analysis. Implementation Science, 14(1), 52.