External Policies and Incentives

A broad construct that includes external strategies to spread interventions including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting [1].

We combined political directives into intentional spread strategies because sometimes directives are incorporated into collaboratives or other spread strategies. Greenhalgh, et al describe “political directives” and include “policy ‘push’” and “external mandates” and cite evidence as strong (direct or indirect) in increasing motivation, though not capacity, of organizations to implement [2, page 610]. Evidence for the influence of guidelines and public reporting is sparse and equivocal. The threat or reality of public reporting may also motivate organizations, especially late-adopters, to implement an intervention in an effort not to look bad compared to their competitors. However, public reporting can also have a negative influence if there is an adversarial relationship between the reporting entity and the target organization. In this context, people may cover-up (compliant implementation) [3] or engage in “box-checking” rather than true committed use. Membership in a collaborative which adds a more active component to semi-public reporting and guidelines may foster successful implementation but formal quality improvement collaboratives have mixed effects [2]. Typically, collaboratives provide the opportunity to benchmark against peers in conjunction with implementing new practices or products. Reimbursement systems and other incentives (usually monetary) that are controlled outside the organization are another external force that can influence implementation [4].