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 and Kahn 1966), and highlights the level at which to focus strategies to improve implementation outcomes.
The original CFIR (Laura J. Damschroder et al. 2009) elaborated 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 (Laura J. Damschroder 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).