This construct includes externally promulgated (governmental or other external entity) policies, regulations, rules, codes, mandates, recommendations, guidelines, directives, or accreditation requirements (Aarons, Hurlburt, and Horwitz 2011; Flottorp et al. 2013; Trisha Greenhalgh et al. 2017; Jennifer Leeman et al. 2019; Mendel et al. 2008; Nilsen and Bernhardsson 2019; Squires et al. 2019), and alignment of implementation of the innovation with these policies and laws (Means et al. 2020). This construct also includes externally generated malpractice liability (Flottorp et al. 2013) and continuing education requirements (Raghavan, Bright, and Shadoin 2008).
The original CFIR (Laura J. Damschroder et al. 2009) stated that “political directives,” “policy push,” and “external mandates” are important implementation determinants. Greenhalgh et al. cite strong evidence of the direct effects of these concepts; they may also have indirect effects by increasing motivation (but not capacity) of settings to implement innovations (T. Greenhalgh, Robert, et al. 2004 p610).