The original CFIR (Laura J. Damschroder et al. 2009) stated 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 and van Eijnatten 2002). This construct includes Greenhalgh’s intraorganizational networks (T. 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 Inner Setting: Communications). Assessments may be informed by social networking (Scott 2000), complexity (Burnes 2005; L. A. Fitzgerald and 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 (T. Greenhalgh, Robert, et al. 2004). Complexity theory posits that relationships between individuals may be more important than individual attributes (Plsek and Wilson 2001), and building these relationships can positively influence implementation (Safran, Miller, and Beckman 2006).
More recent literature has acknowledged the key role of teams (Means et al. 2020; Dy et al. 2015) and how ideally, relationships evolve to build a sense of ‘teamness’ or ‘community’ that may contribute to implementation outcomes (A. C. Edmondson, Bohmer, and Pisana 2001; Amy C Edmondson 2012). The original CFIR (Laura J. Damschroder et al. 2009) stated that teamwork as an essential “core property” for successful implementation of quality improvement initiatives (Ferlie and 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 (A. C. Edmondson, Bohmer, and Pisana 2001). Teamness is a state and is an essential core property for successful implementation (Ferlie and Shortell 2001). More recently, Edmondson has described the role of increasingly dynamic teams working in complex systems like healthcare (Amy C 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 (T. 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 (T. 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 and 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 (Laurie 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, Conn, and Sorra 2001).