Partnerships & Connections

The Inner Setting is networked with external entities, including referral networks, academic affiliations, and professional organization networks.

This construct captures linkages between the Inner Setting and entities in the Outer Setting, including partnerships, collaboratives, professional societies (Aarons et al., 2011; Moullin et al., 2019), referral networks between health and social services (Flottorp et al., 2013), community-academic partnerships, advocacy groups (Moullin et al., 2019), contracts, technical assistance organizations (Aarons et al., 2011; Raghavan et al., 2008), and access to regional data warehouses or membership in systems (e.g., integrated healthcare system, school district) (Aarons et al., 2011; Nilsen & Bernhardsson, 2019).

The original CFIR elaborated further, recognizing that Inner Settings that support and promote external boundary-spanning roles are more likely to implement new practices quickly (Aiken et al., 1980; Baldridge & Burnham, 1975; Barnsley et al., 1998; Greenhalgh, Robert, et al., 2004; Kimberly & Evanisko, 1981). Professional knowledge can arise from increased boundary-spanning activities (Damanpour, 1991) and participation in professional group(s), as well as external training, are associated with implementation success (Simpson & Dansereau, 2007).

There is a negative relationship between linkages with external entities and implementation until clear advantages of the innovation become apparent (Burns & Wholey, 1993; Greenhalgh, Robert, et al., 2004). However, the relationship is positive once the innovation is accepted as the norm by others in the in/formal network (see also External Pressure) (Greenhalgh, Robert, et al., 2004).

In addition, the collective relationships of individuals in a setting with outer entities represent the social capital of the setting (Brehem & Rahn, 1997; Gittell & Vidal, 1998; Gladwell, 2006; Leana & Pil, 2006); increased bridging between the Inner Setting and the Outer Setting builds social capital (Greenhalgh, Robert, et al., 2004; Nilsen & Bernhardsson, 2019).

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

Inclusion Criteria

In addition to organization-level connections between entities, can also Include descriptions of individuals’ outside group memberships and networking done outside the organization.

  • “I am a member of the ADA and go to a conference about once per year.”
  • “Networking is very important to me… I get a lot of ideas.”
  • “I’m president of the local chapter.”
  • “My department pays to send each of us to a conference every year.”

Exclusion Criteria

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

Regarding quantitative measurement of this construct: In a systematic review of quantitative measures related to implementation, McHugh et al. identified seven measures (McHugh et al., 2020). Using PAPERS criteria of measurement quality with an aggregate scale ranging from -9 to +36 (Lewis, Mettert, Stanick, et al., 2021), five measures (71.43%) had sufficient information for assessment and scores ranged from -2 to +6. Results indicate the need for continued development of high-quality measures.

Please contact us with additional measures.

Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 4–23.

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.

Barnsley, J., Lemieux-Charles, L., & McKinney, M. M. (1998). Integrating Learning into Integrated Delivery Systems: Health Care Management Review, 23(1), 18–28.

Brehem, J., & Rahn, W. (1997). Individual Level Evidence for the Causes and Consequences of Social Capital. American Journal of Political Science, 41(3), 999–1023.

Burns, L. R., & Wholey, D. R. (1993). Adoption and abandonment of matrix management programs: Effects of organizational characteristics and interorganizational networks. Academy of Management Journal. Academy of Management, 36(1), 106–138.

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

Flottorp, S. A., Oxman, A. D., Krause, J., Musila, N. R., Wensing, M., Godycki-Cwirko, M., Baker, R., & Eccles, M. P. (2013). A checklist for identifying determinants of practice: A systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science, 8(1), 35.

Gittell, R. J., & Vidal, A. (1998). Community organizing: Building social capital as a development strategy. Sage PublicationsGreenhalgh, 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.

Gladwell, M. (2006). The tipping point how little things can make a big difference. Little, Brown : Hachette Book Group.

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.

Leana, C. R., & Pil, F. K. (2006). Social Capital and Organizational Performance: Evidence from Urban Public Schools. Organization Science, 17(3), 353–366.

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.

McHugh, S., Dorsey, C. N., Mettert, K., Purtle, J., Bruns, E., & Lewis, C. C. (2020). Measures of outer setting constructs for implementation research: A systematic review and analysis of psychometric quality. Implementation Research and Practice, 1, 263348952094002.

Nilsen, P., & Bernhardsson, S. (2019). Context matters in implementation science: A scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Services Research, 19(1), 189.

Raghavan, R., Bright, C. L., & Shadoin, A. L. (2008). Toward a policy ecology of implementation of evidence-based practices in public mental health settings. Implementation Science, 3(1), 26.

Simpson, D. D., & Dansereau, D. F. (2007). Assessing Organizational Functioning as a Step Toward Innovation. NIDA Science & Practice Perspectives, 3(2), 20–28.