The setting in which the Inner Setting exists, e.g., hospital system, school district, state. There may be multiple Outer Settings and/or multiple levels within the Outer Setting (e.g., community, system, state).

Lengnick-Hall et al. call for taking an “open-systems” perspective when conceptualizing boundaries between Outer and Inner Settings “to highlight interdependence between outer and inner contexts and [to] view organizations as part of a broader interdependent system that may range from simple to complex, rigid to flexible, and loosely to tightly coupled” (Lengnick-Hall et al., 2020 p3). Although embracing an open-systems perspective may be challenging, conceptually differentiating internal and external influences on the performance of organizations has been a central tenet of organization science (Katz & Kahn, 1966), and highlights the level at which to focus interventions.

The original CFIR elaborated further on this domain, stating that the Outer Setting is designed to capture macro-level factors that emanate from outside the Inner Setting. The specific factors considered ‘in’ or ‘out’ will depend on the context of the implementation effort (Damschroder, Aron, et al., 2009). For example, outlying clinics may be part of the Outer Setting in one study, but part of the Inner Setting in another study. A social-ecological perspective that recognizes the complex interplay between macro-level factors (e.g., community, economic), meso-level factors (e.g., health systems, clinics), and microsystem-level factors (e.g., units, teams), with individuals is widely applied within implementation. Changes in the Outer Setting can have positive or negative influences on implementation; these constructs are boundary spanning because they are mediated through changes in the Inner Setting (Institute of Medicine, 2001).

Qualitative coding guidelines that are aligned with the Updated CFIR will be added as appropriate.

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

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science: IS, 4, 50. https://doi.org/10.1186/1748-5908-4-50

Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press.

Katz, D., & Kahn, R. L. (1966). The social psychology of organizations. Wiley.

Lengnick-Hall, R., Willging, C., Hurlburt, M., Fenwick, K., & Aarons, G. A. (2020). Contracting as a bridging factor linking outer and inner contexts during EBP implementation and sustainment: A prospective study across multiple U.S. public sector service systems. Implementation Science, 15(1), 43. https://doi.org/10.1186/s13012-020-00999-9