Factors Associated with Higher Implementation Effectiveness

The results of this study showed two differentiating factors that partially explained the differences between the high implementation effectiveness achieved in Hospital B and the medium level of

implementation effectiveness achieved in Hospitals A and C: 1) length of implementation and 2) management engagement.

Length of Implementation

At the time of this study Hospital B had been implementing the HCWM system for 4.5 years, over twice as long as Hospital A and four times longer than Hospital C. This difference in implementation period was associated with implementation effectiveness based on IRAT scores (the longer the

implementation period, the higher the score on the IRAT). The lower scores in Hospitals A and C were mainly due to issues that could be corrected over time (Appendix 6).

The issue of implementation length was also reflected in the interview data from Hospital B. Respondents reported that the first two years of implementation (i.e., the current implementation period of Hospitals A and C) were very difficult. There were no other government hospitals implementing this system at the time so Hospital B was breaking new ground. The staff was comfortable with the status quo and resistant to change. It took about two years to roll the system out to all hospital wards.

Implementation reportedly became easier over time as the system evolved, staff became more engaged and implementation problems were slowly addressed. A few respondents from Hospital B reported that they had now reached the point where the HCWM system was institutionalized and part of mandatory hospital operations in the wards.

Despite these findings from Hospital B, the relationship between implementation length and implementation effectiveness was complex and associated with the time of introduction of the innovation, the hospital governance structure and available resources for implementation (as discussed in Section 5.1). For example, although Hospital A had a much shorter implementation length, the management scaled up the system throughout the hospital in just one year and achieved an implementation

effectiveness score that was slightly below 90% (cutoff for high level). There were several reasons that Hospital A may have achieved this level of scale-up and implementation effectiveness more quickly than Hospital B. Hospital B was a much bigger hospital with a large number of staff, limited resources and complicated political relationships. Hospital A had resources and motivation to scale up the HCWM system quickly. Perhaps more importantly, most respondents in Hospital A were also aware that this new model for HCWM was working successfully in Hospital B. A few respondents in Hospital A had toured the facilities in Hospital B and met the HCWM staff there. This existing model, with 2-3 years of lessons learned and best practices to share, may have shortened the length of time that Hospital A needed to achieve full scale up and a medium-high implementation effectiveness score of 88%.

Hospital C also had a relatively high score on the IRAT given only one year of implementation, indicating that all of the critical pieces were in place for the system (although the IRAT score was only for the four wards of the hospital where the innovation was in place). The slow rollout in Hospital C was similar to that in Hospital B and mainly due to restrictions on availability of space. Based on the

experience from the other two hospitals, implementation effectiveness in Hospital C should improve over time.

These findings suggest that hospitals with limited resources that adopt this innovation can achieve effective implementation quickly but may experience lengthy scale-up periods for facility-wide coverage. In hospitals that have time-bound incentives to implement quickly (such as external certification

processes) and the resources to do so, a high level of implementation effectiveness can be achieved in a relatively short period of time for an entire facility (Table 24).

Management Engagement

Research studies have shown that when an innovation requires employees to work in

collaboration, management support becomes a critical factor in implementation success (138). The non- incineration HCWM system is an example of this type of innovation since it has high task

The management in Hospital B was deeply engaged with and invested in the success of the HCWM system, from idea generation to adoption through four years of implementation. The Hospital Director shaped the implementation context through consistent and clear communication to hospital staff that the innovation was a hospital priority, championing the idea of non-incineration HCWM both within and outside of the hospital. Given the resource and political constraints that government hospitals face in Nepal, this level of management engagement is critical for adoption and implementation of innovations.

In both Hospitals A and C management support during implementation was largely symbolic and there was very little management engagement. Although this was a notable difference between Hospital B and Hospitals A and C, there was no apparent impact on implementation effectiveness in the latter two hospitals, aside from a few comments from hospital staff that they would have liked to see more ongoing visible support from the directors. This might have been due to the presence of strong internal innovation champions on staff at both hospitals. These HCWM Coordinators were appointed by management and in positions of authority over users of the system. Once the top management support was clear and resources dedicated, these coordinators could take over as strong representatives of management.

These findings highlight the complexities of management support and suggest that there is a qualitative difference between management support, which was present in all sites, and management engagement, which was present only in Hospital B (Table 24). In all hospitals, management support was provided for approval to adopt the HCWM system and allocate resources for implementation. This level of basic management support has been shown in multiple studies to be a key factor in implementation success since managers set organizational priorities and control resources within the hospital setting (12,13,113). Management engagement throughout implementation, however, becomes critical in settings where there are special circumstances associated with the innovation—for example, the innovation has not been done elsewhere and the organization is playing a leadership role in pushing forward new ideas; the hospital staff are highly resistance to change; or, the setting is severely resource-constrained and the management must justify continued allocation of resources for the innovation. When conditions are more

conducive to change, engagement of mid-level managers may substitute for engagement of the top management if they have the power and authority to implement change. This finding is consistent with results from other studies where support from mid-level managers was shown to also aid or hinder implementation (108).

Table 24: Differentiating Factors for Levels of Implementation Effectiveness and Implications Differentiating

Factors Implications

Length of Implementation

 First adopters (hospitals that are introducing a completely new

innovation for the country) may experience a long period of resistance to innovation use.

 Implementation improves over time as staff members become more adept at innovation use.

 If resources are available, complete scale-up and high implementation effectiveness can be achieved in a short period of time, especially if the innovation is familiar to staff (e.g., adopted in other hospitals).

Management Engagement

 Management support is different than management engagement.

 Management engagement is critical when the innovation is completely new, staff are resistant to change or the management has to fight for resources for the innovation.

 Mid-level managers can substitute for engagement of top management if they have power and authority.