Facilitating Factors for Implementation Effectiveness

There were four facilitating factors for implementation effectiveness that were salient and strong across all sites: innovation champions; partnerships, IPPs and innovation-values fit for nurses and hospital workers.

Innovation Champions

Innovation champions have been identified in several systematic reviews as a positive influencing factor in innovation implementation in organizational settings (109,118,133). Internal champions,

especially those holding positions of authority within the organization, have been shown to play a key role in encouraging implementation and behavior change among staff (113,127).

The findings in this study were consistent with the literature. The presence of champions in each hospital was shown to be a critical factor in implementation success. The internal champions in Hospitals A and C were both appointed to serve as HCWM Coordinators by the hospital management. Although some studies show that appointed champions are usually ineffective, this was not the case in either hospital (121). These internal champions were reportedly enthusiastic about the implementation of the non-incineration HCWM system and both were influential in creating expectations for innovation use and positive change. This is consistent with the findings from one study that showed that formally designated innovation champions were effective in promoting implementation (113). The effectiveness of these internal champions could also have been because these individuals were chosen based on their pre- existing interest in or inclination to support the new HCWM system.

The presence in two of the hospitals of highly-placed innovation champions, an internal person and an external person, deserves mention. This combination of champions strengthened support for the innovation both within and outside of the hospitals and led to a variety of unforeseen benefits. This internal/external combination of champions is worthy of further study to better understand whether and how this relationship enhances implementation effectiveness (Table 23).

Partnerships

The importance of partnerships in the implementation process has been shown in several studies and systematic reviews (106,118,119,134). Partners can bring technical skills, resources, enthusiasm and different perspectives into the implementation process (109). One study showed that partners and resource organizations are strongly associated with effectiveness of organizational practices (135). In low-income countries like Nepal, often new hospital initiatives will necessarily include one or more external funding or technical assistance partners.

Partnerships have been characterized in the literature as external factors outside of the sphere of control of the organization (135). There are, however, cases where the line between the organization and the partner blurs and a partner becomes embedded within the organizational structure. This may occur

more in organizations in resource-constrained settings where technical partners often work in close proximity with organizational counterparts. This type of symbiotic partner relationship was also seen in this study between NGO A and Hospital B. The partner had, in essence, become part of the hospital HCWM system, working side-by-side with hospital staff and maintaining offices at the hospital. While the partner relationship in the other two hospitals did not develop to this degree, the long term partnership in each location was still a critical, if not the most important factor for implementation success. The passion and determination of NGO A and its leader has clearly pushed forward the implementation of non-incineration HCWM in Nepal. Without this partner it is quite likely that HCWM approaches in Nepal might have taken years to advance beyond incineration.

The findings from this study highlight the need to further explore the dynamics of partner- organization relationships, and how and what type of partnerships may affect innovation implementation in resource-constrained settings (Table 23).

Implementation Policies and Practices

Several studies have demonstrated the importance of developing innovation-specific IPPs that are clearly communicated, realistic and result in the perception by users that implementation is expected, supported and rewarded (108). One study found that, more than the specific content of the IPPs, it was “the consistency of practice and the degree to which they reward the use of the innovation” that affects implementation effectiveness (136). The literature also highlights that different combinations of IPPs can have a similar effect on implementation climate (113).

IPPs were found to be a key factor in implementation effectiveness in this study. Strong IPPs were especially important because all hospitals had dual systems of HCWM in place for periods of time and there was high risk of confusion among staff about the hospital priorities and expectations. This confusion was largely avoided with practices such as the use of clear and consistent signage in all wards where the system was in place and hiring separate HCWM staff for waste collection, transport and recycling.

Although the hospital followed WHO and Nepal national guidelines to set up the HCWM system, the practices in each hospital evolved over time to fit the hospital culture and rhythms, available resources and staffing levels (43,137). There were specific practices at all sites that were notable and are included in the recommendations in Chapter 6: Plan for Change (Table 23).

Innovation-Values Fit – Nurses and Hospital Staff

Innovation-values fit can increase users’ understanding of the rationale behind the innovation and the potential impact of innovation use (136). The study findings showed strong innovation-values fit among the primary innovation user groups in the hospital: nurses, ward attendants and HCWM staff. The types of values that emerged from the data fell into two broad categories: professional values and

community values. Respondents perceived that use of the new HCWM system aligned with their values as healthcare professionals: better patient care, cleaner wards, safer work conditions and improved infection control. Respondents also described how use of the system contributed to the wellbeing of the wider community and that the hospital had a duty to do no harm and manage its own waste.

The study findings also showed weak innovation-values fit for doctors. Since the HCWM system in these hospitals was designed around nurses and ward attendants as primary users and monitors, this did not substantially impact on implementation effectiveness (Table 22).

Table 22: Facilitating Factors for Implementation Effectiveness in All Sites and Implications

Facilitating Factors Implications

Innovation champions

 Appointed internal innovation champions can be effective in promoting change.

 A combination of internal and external champions can be powerful in not just pushing innovation use within the organization but also advocating for recognition of the organization externally.

Partnerships  Partnerships can play a critical role in achieving implementation effectiveness in resource-constrained settings.

 Partners can become an integral part of the organizational structure for innovation implementation.

Implementation Policies and Practices

 Strong IPPs can help avoid confusion when the innovation has not been fully implemented throughout the organization.

 IPPs should be allowed to evolve over time to fit the culture and rhythms of the organization.

Facilitating Factors Implications Innovation-Values Fit

for nurses and hospital workers

 Innovation use can align with the values of users related to different areas, for example, their job, the community and the environment.

 Divergent innovation-values fit within an organization may not effect implementation effectiveness if the innovation-values fit of the primary user groups is strong.