The outer context describes the environment external to the organization, and can include the service and policy environment and characteristics of the individuals who are the targets of the EBP (e.g., patients, consumers). The outer context also includes inter-organizational relationships between entities, including governments, funders, managed care organizations, professional societies, advocacy groups, etc., that influence and make the outer context dynamic.
outer context elements
|Service Environment*||State and federal sociopolitical and economic contexts that influence the process of implementation and delivery/use of the innovation.||Policies; legislation; monitoring and review; auditing; mandates|
|Funding||Fiscal support provided by the system in which implementation occurs. Fiscal support can target multiple levels (e.g., staff training, fidelity monitoring, provision of the innovation/EBP) involved in implementation and delivery/use of the innovation.||Contracting arrangements; Grants; fee-for service, addition to formulary; capitation fees, incentives.|
|Leadership||Characteristics and behaviors of key decision-makers pertinent at all levels who are necessary but not sufficient to facilitate or promote the implementation process and delivery/use of the innovation.||Transformational leadership; Implementation leadership|
|Inter-organizational Environment & Networks||Relationships of professional organizations through which knowledge of the innovation/EBP is shared and/or goals related to the innovation/EBP implementation are developed/established.||Inter-organizational collaboration, commitment, competition, co-opetition|
|Patient/Client Characteristics*||Demographics and individual characteristics of the target population/end user.||Socioeconomic status, health condition, comorbidities, age, gender, motivation|
|Patient/Client Advocacy*||Support or marketing for system change based on consumer needs, priorities and/or demographics.||Client advocacy; class-action lawsuits, consumer organizations|
The inner context refers to the characteristics within an organization such as leadership, organizational structures and resources, internal policies, staffing, practices, and characteristics of individual adopters (e.g., clinicians or practitioners). However, within the inner context there are multiple levels that vary by organization or discipline and may include executive management, middle management, team leaders, or direct service providers (e.g., clinicians, practitioners).
Inner context elements
Organizational Characteristics: Three broad areas appear to be especially important in the early stage of implementation: an organization’s absorptive capacity, readiness for change and receptive context. Absorptive capacity refers to an organization’s preexisting knowledge/skills, ability to use new knowledge, specialization and mechanisms to support knowledge sharing. Organizations that start with good knowledge/skills, can incorporate new knowledge, are highly specialized, and have mechanisms in place to spread knowledge throughout the organization, are much more likely to explore EBPs and eventually initiate them (Damanpour 1991; Ferlie and Shortell 2001; Greenhalgh et al. 2004; Grol et al. 2007).
Individual Adopter Characteristics: At the more micro level, characteristics of individual adopters are important determinants of which agencies will and will not explore or initiate the use of EBPs. Individual adopters can be at the system, organization, or provider level. In reviewing the literature, three features of individual adopters appear to be important: (1) values and goals, (2) social networks and (3) the perceived need for change.
bridging & innovation factors
Bridging factors are deemed to influence the implementation process as the inner context of organizations is influenced by the outer system in which the organization operates, but those influences are reciprocal (e.g., industry lobbyists impacting pharmacy legislation, direct to consumer marketing, etc.)
Bridging factors may include processes such as interagency collaboration, community-academic partnerships.
Innovation factors may include, characteristics of the innovation or EBP characteristics, and/or the fit of the innovation at system, organization, provider, and patient levels.