Guidelines for Implementing Innovations in Hospital Organizations

Josiano Cesar de Sousa Miriam Borchardt Murilo Barros Alves Edithe Oliveira Nogueira About the authors

ABSTRACT

This article presents an approach on the theory of innovation in services and aims to propose a set of guidelines to support management during the implementation of innovations in hospital organizations. A case study was carried out with two hospitals in the northeastern region of Brazil to seek an answer to the following research question: What guidelines can be proposed to support management during the process of implementing innovations in hospital organizations? The collected data were treated with content analysis techniques with the aid of the Atlas.ti software. As a result, it was possible to structure a set of guidelines composed of five stages, capable of supporting the management team during the process of implementing innovations in hospital organizations. The proposed guidelines indicate that to implement innovations, the hospital must arouse to the need to innovate, learn to innovate, reconfigure the environment, implement innovations and monitor results. The article adds academic contributions by exploring the theory of innovation and associating it with the service sector. It presents managerial contributions by proposing a set of guidelines for the implementation of innovations in hospital organizations. Finally, the article presents its limitations and recommendations for future research.

KEYWORDS:
Guidelines; Implementation; Innovation; Hospital Environments; Hospital

RESUMO

Este artigo apresenta uma abordagem sobre a teoria da inovação em serviços e tem como objetivo propor um conjunto de diretrizes para apoiar a gestão durante a implantação de inovações em organizações hospitalares. Um estudo de caso foi realizado junto a dois hospitais da região nordeste do Brasil para buscar resposta à seguinte questão de pesquisa: Que diretrizes podem ser propostas para apoiar a gestão durante o processo implantação de inovações em organizações hospitalares? Os dados coletados foram tratados com técnicas de análise de conteúdo com o auxílio do software Atlas.ti. Como resultado, foi possível estruturar um conjunto de diretrizes composto por cinco etapas, capaz de apoiar a equipe de gestão durante o processo de implantação de inovações em organizações hospitalares. As diretrizes propostas apontam que para implantar inovações o hospital deve despertar para a necessidade de inovar, aprender a inovar, reconfigurar o ambiente, implantar as inovações e monitorar os resultados. O artigo acrescenta contribuições acadêmicas ao explorar a teoria da inovação e associá-la ao setor de serviços. Apresenta contribuições gerenciais ao propor um conjunto de diretrizes para a implantação de inovações nas organizações hospitalares. Por fim, o artigo apresenta suas limitações e recomendações para futuras pesquisas.

PALAVRAS-CHAVE:
Diretrizes; Implantação; Inovação; Ambientes Hospitalares; Hospital

1. INTRODUCTION

The first records on the use of the term innovation date from the end of the 19th century, although the innovation management process has only started to occupy a prominent place in the literature in the beginning of the 20th century when Schumpeter highlighted the importance of companies “creating new products to outperform the competition and stand out in the market" (Śledzik, 2013Śledzik, K. (2013). Schumpeter’s view on innovation and entrepreneurship. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.2257783
https://doi.org/10.2139/ssrn.2257783...
p.3). Already in the 1980s Drucker (1986Drucker, P. (1986). Innovation and Entrepreneurship. Harper Perennial.) pointed out that innovation could contribute to the way companies manage their resources. Years later, Hamel (2000Hamel, G. (2000). Leading the Revolution. Harvard Business School Press.) pointed out that, due to the innovation process, companies needed to reinvent themselves and generate new forms of management, and the adoption of a new attitude favorable to innovation in companies became a managerial challenge for companies to achieve better results.

In the health sector, most innovation processes take place in hospital organizations, which, in turn, are characterized as a subsystem of the health sector of a medical-social nature and whose function is to provide care services, being known as to be organizations where several internal processes occur that are complex, interdependent (Souza et al., 2009Souza, A. A., Guerra, M., Lara, C. O., Gomide, P. L. R., Pereira, C. M., & Freitas, D. A. (2009). Controle de gestão em organizações hospitalares. Revista de Gestão USP, 16(3), 15-29. ) and present managerial challenges.

The importance of management for the innovation process was highlighted by several authors. Djellal and Gallouj (2007Djellal, F., & Gallouj, F. (2007). Innovation in hospitals: A survey of the literature. The European Journal of Health Economics, 8(3), 181-193. https://doi.org/10.1007/s10198-006-0016-3
https://doi.org/10.1007/s10198-006-0016-...
) performed a literature review on innovation in hospitals. Vargas et al. (2014Vargas, E. R., Figueiredo, K. F., Araujo, C. A. S., Bohrer, C. T., & Farias, J. S. (2014). Innovation in Hospitals and the Service-Dominant Logic. Revista de Gestão em Sistemas de Saúde - RGSS, 3(1), 14-26. ) applied the integrative perspective from the investigation of hospital services. Engle et al. (2016Engle, R. L, Lopez, E. R., Gormley, K. E., Chan, J. A., Charns, M. P., & Van, D. L. (2016). What roles do middle managers play in implementation of innovative practices? Health Care Management Review, 42(1), 14-27.) highlighted the importance of the manager's roles in implementing innovative practices. And Helm and Graf (2018Helm, R., & Graf, Y. A. (2018). A capabilities-based service development process for industrial manufacturers. International Journal of Knowledge Management Studies, 9(1), 85-102.) highlighted the importance of managers managing existing relationships and having the necessary competencies to manage organizational resources.

The existing literature on innovation management points to the existence of theoretical gaps, such as those pointed out by Silva (2011Silva, D. O. (2011). Proposta para análise da gestão da inovação em serviços hospitalares: Um estudo no hospital mãe de Deus. [Dissertação de Mestrado]. Universidade do Vale do Rio dos Sinos - São Leopoldo. ), who suggested proposing a methodology for the management of innovation in hospital environments, considering the peculiarities of these environments. Those evidenced by Nyle´n and Holmstro¨m (2015Nyle´n, D., & Holmstro¨m, J. (2015). Digital innovation strategy: A framework for diagnosing and improving digital product and service innovation. Business Horizons, 58(1), 57-67.), by stating that most of the works found analyze the implementation or management of innovation processes related only to the manufacturing sector. Those evidenced by Vagnoni and Oppi (2015Vagnoni, E., & Oppi, C. (2015). Investigating factors of intellectual capital to enhance achievement of strategic goals in a university hospital setting. Journal of Intellectual Capital, 16(2), 331-363. https://doi.org/10.1108/JIC-06-2014-0073
https://doi.org/10.1108/JIC-06-2014-0073...
), who highlighted the need to carry out an assessment from the point of view of quality and results. And those pointed out by Charterina et al (2016Charterina, J., Basterretxea, I., & Landeta, J. (2016). Types of embedded ties in buyersupplier relationships and their combined effects on innovation performance. Journal of Business & Industrial Marketing, 31(2), 152-163.) when pointing out the need to expand research on facilitators and their effects on the capacity for innovation. By considering these gaps, this article contributes to the literature by proposing a set of guidelines to support managers in the process of implementing innovation in hospital organizations.

Intending to contribute to filling the gaps highlighted by Silva (2011Silva, D. O. (2011). Proposta para análise da gestão da inovação em serviços hospitalares: Um estudo no hospital mãe de Deus. [Dissertação de Mestrado]. Universidade do Vale do Rio dos Sinos - São Leopoldo. ) and Nyle´n and Holmstro¨m (2015Nyle´n, D., & Holmstro¨m, J. (2015). Digital innovation strategy: A framework for diagnosing and improving digital product and service innovation. Business Horizons, 58(1), 57-67.), this article was designed to seek an answer to the following research problem: What guidelines can be proposed to support management during the process of implementing innovations in hospital organizations? To answer this question, the article was prepared with the aim of proposing a set of guidelines to support management during the implementation of innovations in hospital organizations.

As a research method, a qualitative approach was adopted (Ketokivi & Choi, 2014Ketokivi, M., & Choi, T. (2014). Renaissance of case research as a scientific method. Journal of Operations Management, 32(5), 232-240. https://doi.org/10.1016/j.jom.2014.03.004
https://doi.org/10.1016/j.jom.2014.03.00...
), of an exploratory nature, through a case study, and allowed the collection of primary data, through interviews guided by a semi-structured script. Content analysis techniques were also used (Walter & Bach, 2015Walter, S. A., & Bach, T. M. (2015). Adeus papel, marca-texto, tesoura e cola: inovando o processo de análise de conteúdo por meio do atlas.ti. Administração Ensino e Pesquisa, 16(2), 275-308.) with the help of the Atlas.ti software - Version 8 (Nelson et al., 2018Nelson, M. B., Riley, K., & Arellano, K. (2018). Adding a parent to the brain tumor team: Evaluating a peer support intervention for parents of children with brain tumors. Journal of Pediatric Oncology Nursing, 35(3), 218-228. https://doi.org/10.1177%2F1043454218762797
https://doi.org/10.1177%2F10434542187627...
) and the Lucicart software was used to edit the generated figures.

In addition to this introduction, the article presents the following structure: section 2 presents the theoretical reference. Section 3 presents the research method used. Section 4 discusses the presentation and analysis of data based on the case study developed and, finally, section 5 presents the final considerations, highlighting the theoretical/academic and managerial contributions of the article, in addition to its limitations and suggestions for future research.

2. THEORETICAL REFERENCE

2.1. The Theory of Innovation

Although there are records of the use of the term innovation even in the late 1880s, the records of greatest influence for the construction of a theory of innovation are attributed to Schumpeter, who in his early writings defined innovation as "an industrial mutation process, which it incessantly revolutionizes the economic structure from within, incessantly destroying the old, incessantly creating a new one" (Śledzik, 2013Śledzik, K. (2013). Schumpeter’s view on innovation and entrepreneurship. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.2257783
https://doi.org/10.2139/ssrn.2257783...
, p. 3). The OSLO manual highlights that the work developed by Schumpeter had a great influence on the theories of innovation (OECD, 1997OECD. (1997). Manual de Oslo - Diretrizes para coleta e interpretação de dados sobre inovação. (3 ed.). FINEP.). The theory of innovation, developed by him in the early 1920s, was considered as "a driving force for economic growth" (Kühl & Cunha, 2013Kühl, M. R., & Cunha, J. C. (2013). Obstáculos à implementação de inovações no Brasil: como diferentes empresas percebem sua importância. BBR Brazilian Business Review, 10(2), 1-25., p. 4).

In his writings, Schumpeter proposed the existence of five types of innovation: “i) launch of a new product [...]; ii) application of new production methods [...]; iii) opening a new market [...]; iv) acquisition of new sources of raw material supply [...]; and v) new industry structure" (Śledzik, 2013Śledzik, K. (2013). Schumpeter’s view on innovation and entrepreneurship. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.2257783
https://doi.org/10.2139/ssrn.2257783...
p.3). This approach set precedents for new classifications. The OSLO Manual, for example, defines four types of innovations: a) product innovation; b) Process innovations; c) organizational innovations; e, d) marketing innovations (OECD, 1997OECD. (1997). Manual de Oslo - Diretrizes para coleta e interpretação de dados sobre inovação. (3 ed.). FINEP.).

Since Schumpeter highlighted the importance of innovation for companies to stand out in the market and gain competitive advantage over their competitors, several authors (Wu, 2014Wu, C.-W. (2014). The study of service innovation for digiservice on loyalty. Journal of Business Research, 67(5), 819-824.; Xu et al., 2015Xu, Y., Enrique Ribeiro-Soriano, D., & Gonzalez-Garcia, J. (2015). Crowdsourcing, inovação e desempenho da empresa. Management Decision, 53(6), 1158-1169. https://doi.org/10.1108/MD-06-2014-0408
https://doi.org/10.1108/MD-06-2014-0408...
; Nyle´n & Holmstro¨m, 2015Nyle´n, D., & Holmstro¨m, J. (2015). Digital innovation strategy: A framework for diagnosing and improving digital product and service innovation. Business Horizons, 58(1), 57-67.; Tuti et al., 2016Tuti, T., Bitok, M., Paton, C., Makone, B., Malla, L., Muinga, N., Gathara, D., & English, M. (2016). Innovating to enhance clinical data management using non-commercial and open-source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. Journal of the American Medical Informatics Association, 23(1), 184-192.; Cândido & Sousa, 2017Cândido, A. C., & Sousa, C. (2017). Open innovation practices in strategic partnerships of cloud computing providers. Journal of Technology Management & Innovation, 12(2), 59-67. ) have been dedicated to studying the theme of innovation. However, most of the approaches observed in the literature were dedicated to studying the theme from the perspective of the manufacturing sector (Albertin et al., 2017Albertin, M. R., Elienesio, M. L. B., Aires, A. S., Pontes, H. L. J., & Aragão,D. P., Jr. (2017). Major tech innovations in industry 4.0 and its applications and implications in manufacturing. In XXIV Simpósio de engenharia de produção. Bauru, SP, Brasil.), leaving out of this approach the service sector (Nilashi et al., 2016Nilashi, M., Ahmadi, H., Ahani, A., Ravangard, R., & Ibrahim, O. B. (2016). Determining the importance of Hospital Information System adoption factors using Fuzzy Analytic Network Process (ANP). Technological Forecasting & Social Change, 111, 244-264. ).

The process of technological development and innovation had a special acceleration from the first industrial revolution (Steele & Clarke, 2013Steele, R., & Clarke, A. (2013). The internet of things and next-generation public health information systems. Communications and Network, 5(3), 4-9. doi:10.4236/cn.2013.53B1002
https://doi.org/10.4236/cn.2013.53B1002...
) and from the 1980s onwards, the observed technological changes allowed the development of new processes and generated new managerial challenges for the management of internal and external resources needed to generate competitive advantage in the organizational environment (Wu, 2014Wu, C.-W. (2014). The study of service innovation for digiservice on loyalty. Journal of Business Research, 67(5), 819-824.) and this led to the search for an approach to innovation more suited to the service sector. In this sense, authors such as Djellal and Gallouj (2007Djellal, F., & Gallouj, F. (2007). Innovation in hospitals: A survey of the literature. The European Journal of Health Economics, 8(3), 181-193. https://doi.org/10.1007/s10198-006-0016-3
https://doi.org/10.1007/s10198-006-0016-...
) and Vargas et al. (2014Vargas, E. R., Figueiredo, K. F., Araujo, C. A. S., Bohrer, C. T., & Farias, J. S. (2014). Innovation in Hospitals and the Service-Dominant Logic. Revista de Gestão em Sistemas de Saúde - RGSS, 3(1), 14-26. ) presented contributions on the study of innovation in hospital environments.

2.2. Approaches to service innovation

In recent years, efforts have been made to build a theory of innovation that is sufficiently comprehensive to encompass goods and services without, however, setting aside their differences (Vargas, 2006Vargas, E. R. (2006). A dinâmica da inovação em hospitais: o caso dos serviços hospitalares no Brasil e na França. [Tese de Doutorado ]. Universidade Federal do Rio Grande do Sul. ). The main discussions aimed to debate the compatibility between the neo-Schumpeterian theory of innovation and the efforts to establish a new integrative approach to innovation in services. Among the main advances observed, three initial lines are worth mentioning: the first, which is based on the technological origin of the innovations - Technician Approach; a second, which presents the singularities of the innovation process relevant to service activities - Service-Based Approach; and the third, which seeks to integrate these two strands and, with this, develop a theory of innovation in services - Integrating Approach (Vargas et al., 2014Vargas, E. R., Figueiredo, K. F., Araujo, C. A. S., Bohrer, C. T., & Farias, J. S. (2014). Innovation in Hospitals and the Service-Dominant Logic. Revista de Gestão em Sistemas de Saúde - RGSS, 3(1), 14-26. ).

The technicist approach was advocated by Richard Barras in the 1980s. He sought to draw attention to the importance of the service sector in the innovation process. This model became known as the product's reverse cycle and aimed to promote an analysis of the changes caused in services because of the computerization process. This approach argues that new services or improved services are a result of the introduction of new technologies. Although the model he developed was considered useful, Barras was unable to consolidate his theory, but he was recognized as the first to seek the construction of a theory of innovation in services (Vargas, 2006Vargas, E. R. (2006). A dinâmica da inovação em hospitais: o caso dos serviços hospitalares no Brasil e na França. [Tese de Doutorado ]. Universidade Federal do Rio Grande do Sul. ).

The service-based approach emerged in contrast to the technicist approach and aimed to identify the particularities of the service production process and, therefore, show that even if the service provision activity is intangible, it is possible to promote innovations in the performance of services based on of its relational character and the irreversibility of its production process (Vargas, 2006Vargas, E. R. (2006). A dinâmica da inovação em hospitais: o caso dos serviços hospitalares no Brasil e na França. [Tese de Doutorado ]. Universidade Federal do Rio Grande do Sul. ). In this perspective, the OSLO manual highlights that innovations in the service sector “may include important improvements with regard to how they are offered (for example, in terms of efficiency or speed), the addition of new functions or features in existing services, or the introduction of entirely new services" (OECD, 1997OECD. (1997). Manual de Oslo - Diretrizes para coleta e interpretação de dados sobre inovação. (3 ed.). FINEP., p. 58). This approach distanced itself from the original conception of Schumperter in 1911 and considers customer relations as a source of learning, which led to the emergence of a new type of innovation called contingent innovation or ad-hoc adhocratic, characterized by “(social) interactive construction of a solution strategic, organizational, social, legal, etc.) to a specific problem posed by the customer" and which involves the user as a co-producer of the innovation (Vargas et al., 2014Vargas, E. R., Figueiredo, K. F., Araujo, C. A. S., Bohrer, C. T., & Farias, J. S. (2014). Innovation in Hospitals and the Service-Dominant Logic. Revista de Gestão em Sistemas de Saúde - RGSS, 3(1), 14-26. , p. 6).

The integrative approach, in turn, was presented as a proposal to promote the integration of innovation in goods and services in a single theory. Even considering that there are differences between these activities, this approach argues that the emphasis should be on the particularities of the manufacturing or services activity, depending on the intensity of the relationship with the customer (Vargas, 2006Vargas, E. R. (2006). A dinâmica da inovação em hospitais: o caso dos serviços hospitalares no Brasil e na França. [Tese de Doutorado ]. Universidade Federal do Rio Grande do Sul. ). The approach also defends that there tends to be a convergence between manufacturing and services.

2.3. Development of innovations in hospital organizations

The innovation scenario has intensified in recent decades, especially with the advent of the fourth industrial revolution, referred to in the literature as industry 4.0 (Lu, 2017Lu, Y. (2017). Industry 4.0: A survey on technologies, applications and open research issues. Journal of Industrial Information Integration, 6, 1-10.). This brought new management challenges, required the structuring of a management model focused on the development of new skills and continuous learning, and made companies wake up to the need to develop new management tools to sustain themselves in the conduct of innovation processes (Nyle´n & Holmstro¨m 2015Nyle´n, D., & Holmstro¨m, J. (2015). Digital innovation strategy: A framework for diagnosing and improving digital product and service innovation. Business Horizons, 58(1), 57-67.).

When it comes to innovation in hospital services, one of the great challenges observed lies in combining a theoretical view of services with the complexity of hospital services, which are addressed in the literature, according to Djellal (2004Djellal, F. (2004). L’hospital invovateur: de l’innovation médical à l’innovation de servisse. Masson.) , in four recurrent approaches: the first one that treats the hospital as the place where the production of services takes place (production function); a second that perceives the hospital as a set of capabilities (technical and biopharmacological); the third which sees the hospital as an information system (managerial and medical) and the fourth, which presents the hospital as a provider of complex services.

The management of innovation in hospital organizations is related to the need to develop skills and competences to create and manage an organizational environment that, in addition to being concerned with health care, also facilitates the dissemination of an innovative philosophy in conducting processes and procedures. For this reason, the involvement of management became the subject of studies (Tuti et al., 2016Tuti, T., Bitok, M., Paton, C., Makone, B., Malla, L., Muinga, N., Gathara, D., & English, M. (2016). Innovating to enhance clinical data management using non-commercial and open-source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. Journal of the American Medical Informatics Association, 23(1), 184-192.; Abuhejleh et al., 2016Abuhejleh, A., Dulaimi, M., & Ellahham, S. (2016). Using lean management to leverage innovation in healthcare projects: Case study of a public hospital in the UAE. BMJ Innovations, 2(1), 22-32. ), to analyze and implement improvements in the models for driving innovation in hospital organizations, aiming to reduce the impacts of changes caused by the innovation process and help companies in the process of learning to innovate.

2.4. The innovation management process in the hospital organization

The study of skills and abilities necessary for the development of an efficient management method leads to the need to carry out an analysis of the organizational environment, to reflect on the need to coordinate and integrate different flows for collective learning (Prahalad & Hamel, 1990Prahalad, C. K., & Hamel, C. (1990) The core capability of the corporation. Harvard Business Review, 68(3), 79-91. ).

Another important factor for the process of managing the implementation of innovations in hospital organizations is the evaluation of the results of the implemented innovations. Therefore, ideally, the management team should prepare or identify the main key performance indicators - KPI (Ioan et al., 2012Ioan, B., Nestian, A. S., & Tiţă, S-M. (2012). Relevance of Key Performance Indicators (KPIs) in a Hospital Performance Management Model. Journal of Eastern Europe Research in Business & Economics, 2012, 674169. https://doi.org/10.5171/2012.674169
https://doi.org/10.5171/2012.674169...
; Si et al., 2017Si, S., You, X., Liu, H., & Huang, J. (2017). Identifying Key Performance Indicators for Holistic Hospital Management with a Modified DEMATEL Approach. International Journal of Environmental Research and Public Health, 14(8), 934. https://doi.org/10.3390/ijerph14080934
https://doi.org/10.3390/ijerph14080934...
) needed to assess the individual involvement of each team member and develop a methodology to establish and monitor the objectives and key results - OKRs (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) aligned with the organizational objectives.

The OKRs methodology was advocated in the early 1990s by Andy Grover, CEO of Intel, with the function of defining goals and performance metrics for the organization (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ). The method proposed by Grove for business management indicates the necessary conditions for conducting the process of evaluating the OKRs and can be carried out using two steps: a cycle of strategic reflection and a cycle of constant monitoring, as shown in Figure 1 below:

Figure 1 -
OKR Cycles

According to the authors, the function of the monitoring cycles is to assess whether and how the objectives are being achieved, which is why they occur interactively between sectors. Strategic reflection cycles, in turn, have the function of helping the organization to fulfill its institutional purpose (mission and vision) and occur whenever the organization identifies the need to readjust its strategy to a new market reality.

Proposing guidelines to support management in the process of implementing innovations can contribute to the generation of knowledge and the accumulation of experiences, acting as a driver for collective learning, in addition to developing a continuous learning system so that the hospital will be able to learn from the experience of employees and from all the links involved in its value chain and, therefore, contribute to the generation of competitive advantage.

3. RESEARCH METHOD

This article was prepared using a qualitative approach (Ketokivi & Choi, 2014Ketokivi, M., & Choi, T. (2014). Renaissance of case research as a scientific method. Journal of Operations Management, 32(5), 232-240. https://doi.org/10.1016/j.jom.2014.03.004
https://doi.org/10.1016/j.jom.2014.03.00...
), exploratory in nature, through a case study, carried out in the first half of 2020 in two private, small, low, and medium complexity, for-profit, non-research hospitals located in the northeast region of Brazil. The case study strategy was chosen because it is a type of empirical research used to seek to understand a phenomenon in its real context (Dresch et al., 2015Dresch, A., Lacerda, D. P., & Antunes, J. A. V., Jr. (2015). Design Science Research: Research Method for Advancement of Science and Technology. Bookman.) and that it is suitable for studying a phenomenon in depth.

As a collection method, in addition to secondary data, the research used primary data, raised in the case study, which was conducted through interviews, using a semi-structured script, with subjective questions, elaborated based on the researched literature and aimed at two different audiences: the tactical level managers and the operational level employees of the hospitals surveyed, where, in total, 39 employees were surveyed. To develop an appropriate approach to achieving the objectives, the analysis method was based on the content analysis technique (Walter & Bach, 2015Walter, S. A., & Bach, T. M. (2015). Adeus papel, marca-texto, tesoura e cola: inovando o processo de análise de conteúdo por meio do atlas.ti. Administração Ensino e Pesquisa, 16(2), 275-308.) with categories defined using the Atlas.ti software - Version 8 (Nelson et al., 2018Nelson, M. B., Riley, K., & Arellano, K. (2018). Adding a parent to the brain tumor team: Evaluating a peer support intervention for parents of children with brain tumors. Journal of Pediatric Oncology Nursing, 35(3), 218-228. https://doi.org/10.1177%2F1043454218762797
https://doi.org/10.1177%2F10434542187627...
) for systematizing the observations made in the surveyed companies and the Lucicart software was used to edit the generated figures. The collected data were divided and organized into blocks (axes), where each block represents an analyzed criterion. Thus, data analysis was organized by categorizing the information collected during the interview, according to the assigned categories.

The purpose of the analyzes carried out was not to carry out a comparative analysis between the two companies, but rather to identify converging, divergent, similar, or complementary aspects between the investigated hospitals, to highlight the considerations presented. All observations made were consolidated and analyzed to base the proposal of a set of guidelines to support hospital management when implementing innovations.

3.1. Companies surveyed

The research necessary for the elaboration of this article had as unit of analysis two hospitals located in the Northeast region of Brazil. The first hospital (Hosp-1) has 42 beds and has 147 employees. In this hospital, a total of 20 employees were interviewed, corresponding to a percentage of 13.61% of the staff, distributed among 9 operational team employees and 11 tactical level managers. The repeatability exhaustion criterion was used to determine the number of employees interviewed.

The second hospital (Hosp-2) has 44 beds and 248 employees. In this hospital, a total of 19 employees were interviewed, corresponding to a percentage of 7.70% of the staff, distributed among 13 employees of the operational team and 06 managers of tactical level. The accessibility criterion determined the number of collaborators surveyed, since, during the research, the hospital restricted access to the team because of the COVID-19 pandemic in Brazil.

In each hospital, the survey respondents were selected based on two criteria: occupying a managerial position (tactical level manager, head of sector or section) or being an operational member of one of these managers' teams. Respondents were contacted “on-the-spot” during their work shift. Data were collected in the first half of 2020 through the application of a semi-structured questionnaire, with questions based on the researched literature and focused on seeking the respondents' perception of how the process of implementing innovations is conducted in the surveyed hospitals.

4. PRESENTATION AND DATA ANALYSIS

After processing the data collected with the case study, the information generated was grouped into four categories of analysis, to reflect the essence of the responses of the two surveyed audiences (employees and managers of the hospitals) and allow an efficient discussion in the light of existing literature and, with this, support the proposals that will be presented.

The first structured category presents information on how hospitals arouse to identify the need to innovate. The second category points out how the internal learning process is and reflects what needs to be done so that hospitals can learn to innovate. The third category specifically addresses how the innovation management process is in the researched hospitals, highlighting successes and weaknesses. The fourth and last category discusses the barriers and facilitators of the innovation process. The analysis of the categories referring to the two audiences surveyed in each of the hospitals is presented below, addressing first the employees (Figure 2), then the managers (Figure 3):

Figure 2
Research analysis categories, Hospital 1 employees

Figure 3 -
Research analysis categories, Hospital 2 employees

In the first category of analysis, the responses presented by the employees of the two hospitals reflect that they do not use a single methodology, program, or structured procedure to identify opportunities for innovation or to generate new ideas. Although collaborators point out that it is possible to present ideas for innovation, when this occurs, they present their ideas to the tactical level managers, and they make the presentation to the hospital board.

Employees also stated that most innovation opportunities arise from problem identification, that is, in a reactive way. Although the problems are considered as generating sources of innovations, Djellal and Gallouj (2007Djellal, F., & Gallouj, F. (2007). Innovation in hospitals: A survey of the literature. The European Journal of Health Economics, 8(3), 181-193. https://doi.org/10.1007/s10198-006-0016-3
https://doi.org/10.1007/s10198-006-0016-...
) highlight that, due to the organizational complexity of a hospital, it has many other sources of innovation that can be explored.

In the second category of structured analysis, it was possible to observe that the responses presented by employees of the two hospitals highlight that there is no suitable work environment for the practice of innovation and that employees understand that they are not heard or do not participate in the innovation process. Employees highlighted the need to create a harmonious and adequate climate for the practice of innovation to encourage the team's participation in the process.

When analyzing the literature, Khademi (2019Khademi, B. (2019). The ecosystem knowledge explorer: A tool to systematically discover external knowledge. Technology Innovation Management Review, 9(7), 28-40. http://doi.org/10.22215/timreview/1253
http://doi.org/10.22215/timreview/1253...
) emphasizes that it is essential for any company to have an adequate ecosystem for the practice of innovation. And Heidemann et al. (2016Heidemann, C., Du, Y., Paprott, R., Haftenberger, M., Rathmann, W., & Scheidt‐Nave, C. (2016). Temporal changes in the prevalence of diagnosed diabetes, undiagnosed diabetes and prediabetes: findings from the German Health Interview and Examination Surveys in 1997-1999 and 2008-2011. Diabetic Medicine, 33(10), 1406-1414. https://doi.org/10.1111/dme.13008
https://doi.org/10.1111/dme.13008...
) highlights that an open innovation environment provides three benefits: sharing knowledge; cost reduction; and the speed of development.

The analyzes carried out in the third category allowed us to observe that the employees of the two hospitals understand that, in the team management process, one of the biggest deficiencies is the communication process adopted by the hospitals. In the employees' view, communication is flawed, and they are often not communicated about the changes with the necessary time to prepare for them. The employees also stated that the process of evaluating the results obtained with the implementation of innovations is not carried out in a standardized way. In the literature, Inomata (2017Inomata, D. O. (2017). Redes colaborativas em ambientes de inovação: Uma análise dos fluxos de informação. [Tese submetida ao Programa de Pós-Graduação em Ciência da Informação ]. Universidade Federal de Santa Catarina.) states that when there is an effective management, it is possible to significantly increase the company's income and level of innovation.

The analyzes carried out in the fourth category of the survey allowed us to identify what employees consider as barriers and facilitators of the innovation process. In this aspect, employees highlight as a barrier the fact that people are resistant to change and that older employees are more resistant to the innovation process. When analyzing the facilitators, they highlighted the fact that there is a perception that innovations streamline services and improve the hospital's results, making it more competitive. The employees also highlighted that there is a perception that the team grows together with the hospital.

Once the analysis of the responses of the employees of the two hospitals had been completed, we set out to analyze the responses presented by the tactical level managers. These managers are supervisors, team leaders or sector coordinators. The analysis of the answers presented by the hospital managers is presented below (Figures 4 and 5):

Figure 4 -
Research analysis categories, Hospital 1 managers

Figure 5 -
Research analysis categories, Hospital 2 managers

When analyzing the responses presented by managers in the first category of analysis, it was possible to observe that they claim that there is no structured process for identifying opportunities for improvement in hospitals, which confirms the position previously presented by employees. Another point that corroborates the notes presented by employees is that managers also report that the process of identifying opportunities for improvement often takes place through the identification of problems or constraints, which confirms the hospitals' reactive model of action.

The managers of the two hospitals stated that there is no type of structured procedure to promote the exchange of experience with other institutions and, when this happens, it occurs due to the personal relationship between the hospital employee and the other institution, however, there is nothing formalized. As for internal learning, they confirmed that employees do not feel that they participate in the innovation process and understand that, when the process happens, it takes place in an imposing manner.

In the literature, Soda et al. (2017Soda, G., Stea, D., & Pedersen, T. (2017). Network structure, collaborative context, and individual creativity. Journal of Management, 45(4).) draw attention to the fact that managerial decisions can affect the involvement of employees and the climate of collaboration at work. Teece et al. (1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.) emphasize the importance of recognizing the need for innovation and building internal competences to address rapidly changing environments and Souza et al. (2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.) highlight that it is necessary to perceive opportunities and learn from perceived opportunities.

In the second category of analysis, the analyzes carried out contributed to verifying that: it is possible to identify factors that contribute to the successful implementation of innovations in hospital environments. These factors are involving the team and middle management (tactical level) in the innovation process; involve partners and stakeholders; valuing human capital; and create an ecosystem suitable for the practice of innovation so that the hospital can learn to innovate.

Learning to innovate, therefore, goes through the phase of involving collaborators and partners (Kähkönen et al., 2017Kähkönen, A., Lintukangas, K., Ritala, P., & Hallikas, J. (2017). Supplier collaboration practices: Implications for focal firm innovation performance. European Business Review, 29(4), 402-418. https://doi.org/10.1108/EBR-04-2016-0058
https://doi.org/10.1108/EBR-04-2016-0058...
) in the innovation process, because, according to Prokop et al. (2019Prokop, V., Stejskal, J., & Hudec, O. (2019). Collaboration for innovation in small cee countries. Business Administration and Management, 22(1), 130-144.), human capital has a singular importance in this process and people are fundamental for the company to generate and use knowledge (Abreu & Urze, 2016Abreu, A., & Urze, P. (2016). System thinking shaping innovation ecosystems. Open Engineering, 6(1), 418-425. https://doi.org/10.1515/eng-2016-0065
https://doi.org/10.1515/eng-2016-0065...
) and, with this, create an innovation ecosystem (Soda et al., 2017Soda, G., Stea, D., & Pedersen, T. (2017). Network structure, collaborative context, and individual creativity. Journal of Management, 45(4).) that facilitates organizational learning.

When analyzing the perception of managers about the third category of analysis, corresponding to the process of managing the team, it was observed that some of the allegations presented by employees are also corroborated by managers, confirming that there are flaws in the team management process for the innovation process.

A synthesis of the perceptions of the managers of the two hospitals points to the need to improve the work environment and develop a standardized, efficient communication process that takes the opinion of the managers into account. They also pointed out that it is necessary to structure methods for the implementation and evaluation of innovations, as each manager intuitively conducts the process. In this sense, the literature highlights the need to adopt performance indicators (Ioan et al., 2012Ioan, B., Nestian, A. S., & Tiţă, S-M. (2012). Relevance of Key Performance Indicators (KPIs) in a Hospital Performance Management Model. Journal of Eastern Europe Research in Business & Economics, 2012, 674169. https://doi.org/10.5171/2012.674169
https://doi.org/10.5171/2012.674169...
; Si et al., 2017Si, S., You, X., Liu, H., & Huang, J. (2017). Identifying Key Performance Indicators for Holistic Hospital Management with a Modified DEMATEL Approach. International Journal of Environmental Research and Public Health, 14(8), 934. https://doi.org/10.3390/ijerph14080934
https://doi.org/10.3390/ijerph14080934...
) to assess the team's performance and result indicators (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) to assess the achievement of organizational goals to then assess whether the company managed to achieve its main results.

In the analysis of the fourth category, it was possible to observe that managers have a perception that is like the perceptions of employees, which demonstrates an alignment of views on the organizational environment. Managers pointed out people's resistance to change as the main barrier, highlighting that there is a lack of integration between the teams. They also highlighted that the hospital environment discourages the practice of innovation and that the hospitals surveyed do not have a program to generate new ideas. They also pointed out the existence of financial and bureaucratic barriers. As for the facilitators, they highlighted the existence of people with an innovative profile in the team and the creation of an environment where everyone can participate, presenting ideas and criticism.

When comparing the information collected in hospitals with the approaches in the literature, it can be highlighted that it is essential to involve managers in the innovation process (Tuti et al., 2016Tuti, T., Bitok, M., Paton, C., Makone, B., Malla, L., Muinga, N., Gathara, D., & English, M. (2016). Innovating to enhance clinical data management using non-commercial and open-source solutions across a multi-center network supporting inpatient pediatric care and research in Kenya. Journal of the American Medical Informatics Association, 23(1), 184-192.; Abuhejleh et al., 2016Abuhejleh, A., Dulaimi, M., & Ellahham, S. (2016). Using lean management to leverage innovation in healthcare projects: Case study of a public hospital in the UAE. BMJ Innovations, 2(1), 22-32. ), since they are responsible for coordinating and integrate the team into collective learning flows (Prahalad & Hamel, 1990Prahalad, C. K., & Hamel, C. (1990) The core capability of the corporation. Harvard Business Review, 68(3), 79-91. ) to interact and reconfigure internal competences (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.) aiming to improving organizational competitiveness (Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.).

It was also possible to highlight an alignment regarding the identification of the main barriers and facilitators, with those pointed out by Manca et al. (2018Manca, C., Grijalvo, M., Palacios, M., & Kaulio, M. (2018). Collaborative workplaces for innovation in service companies: Barriers and enablers for supporting new ways of working. Service Business, 12, 525-550. https://doi.org/10.1007/s11628-017-0359-0
https://doi.org/10.1007/s11628-017-0359-...
), which highlight the resistance to change, lack of integration between management and the base, low degree of employee involvement, lack of infrastructure and inadequate organizational culture to practice innovation.

The main findings of the case study, which served as the basis for the proposal of the guidelines are presented in the table below (Table 1), where the last column, referring to the steps, presents numbers that are repeated, depending on the groupings that will be carried out after, in the structuring of the proposed guidelines:

Table 1 -
Main findings of the case study.

Considering the above and as a result of the analysis carried out, it was possible to propose a set of guidelines that can contribute to supporting managers when conducting innovation implementation processes in hospital organizations. The guidelines developed were based on the deficiencies pointed out by the hospitals in the case study, as well as using as a foundation the weightings found in the researched literature and were structured in five steps, each of which corresponds to a part of a macro process that, together, constitute the guidelines proposed by this article.

For each of the five steps, a set of guidelines was prepared to support management in the process of implementing innovations in hospital organizations and were structured in a sequential manner, where the result of the monitoring step generates the need to arouse to a new process of innovation, which constitutes a virtuous cycle. The steps are shown in Figure 6 below and will be detailed below:

Figure 6 -
Proposed steps for implementing innovations in hospital organizations

Step I - AROUSE

The hospital must be able to recognize the need to innovate and detect existing opportunities and threats (Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.; Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) in the internal or external environment. Then, it must eliminate the restrictions that prevent or impede the innovation process and it must focus on developing the necessary internal skills (Dynamic Capabilities) for the innovation process (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.) to obtain competitive advantage. As proposed for this step, the hospital must observe the following guidelines: perform an initial diagnosis on the need to implement improvements; recognize the need to innovate; and identify opportunities for innovation.

Step II: LEARN TO INNOVATE

The hospital needs to understand that innovation management is a learned skill and, therefore, it must focus efforts to seek to learn from the perceived opportunities (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.; Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.) to involve employees and managers tactical level in the innovation process (Birken et al., 2012Birken, S. A., Lee, S.-Y. D., & Weiner, B. J. (2012). Uncovering middle managers’ role in healthcare innovation implementation.Implementation Science, 7(1), 28.).

At this stage, the objectives and key results (OKRs) must be defined, and an organizational climate must be created that allows for collaborative involvement - bottom-up and not just imposing - top-down (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ). After that, it is necessary to define the roles of employees and managers in the innovation implementation process (Birken et al., 2012Birken, S. A., Lee, S.-Y. D., & Weiner, B. J. (2012). Uncovering middle managers’ role in healthcare innovation implementation.Implementation Science, 7(1), 28.) and, when necessary, involve partners and key people in the innovation process (Johnston & Huggins, 2016Johnston, A., & Huggins, R. (2016). The Spatio-Relational Nature of Urban Innovation Systems: Universities, Knowledge Intensive Business Service Firms, and Collaborative Networks. Journal of Urban Technology, 23(1). https://doi.org/10.1080/10630732.2015.1090192
https://doi.org/10.1080/10630732.2015.10...
; Shamsuzzoha et al., 2017Shamsuzzoha, A., Al-Kindi, M., & Al-hinai, N. (2017). Open Innovation in Small and Medium Size Enterprises - Perspective from Virtual Collaboration. International Journal of Engineering and Technology Innovation, 8(3), 173-190.; Prokop et al., 2019Prokop, V., Stejskal, J., & Hudec, O. (2019). Collaboration for innovation in small cee countries. Business Administration and Management, 22(1), 130-144.) to then coordinate and integrate the flows to generate collective learning (Prahalad & Hamel, 1990Prahalad, C. K., & Hamel, C. (1990) The core capability of the corporation. Harvard Business Review, 68(3), 79-91. ). The proposal for carrying out this step is that the hospital must observe the following guidelines: define objectives and key results to be achieved - OKRs; identify the resources needed; develop policies, implementation practices and the roles of those involved; and involve key people and partners.

Step III: RECONFIGURE THE ENVIRONMENT

At this stage, the hospital must understand that, often, the complexity and dynamics of the hospital environment (Souza et al., 2009Souza, A. A., Guerra, M., Lara, C. O., Gomide, P. L. R., Pereira, C. M., & Freitas, D. A. (2009). Controle de gestão em organizações hospitalares. Revista de Gestão USP, 16(3), 15-29. ) end up not encouraging the team to participate in the innovation process. Therefore, it is necessary to carry out a self-analysis of its functional structure and assess the quality of the infrastructure and available resources to then promote the necessary adjustments.

Hospitals often need to reconfigure the environment and internal competencies (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.; Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.) to encourage team engagement. The environment must be conducive and have clear rules to avoid conflicts of interest (Helm & Graf, 2018Helm, R., & Graf, Y. A. (2018). A capabilities-based service development process for industrial manufacturers. International Journal of Knowledge Management Studies, 9(1), 85-102.) in the innovation process. The environment must also be flexible (Manca et al., 2018Manca, C., Grijalvo, M., Palacios, M., & Kaulio, M. (2018). Collaborative workplaces for innovation in service companies: Barriers and enablers for supporting new ways of working. Service Business, 12, 525-550. https://doi.org/10.1007/s11628-017-0359-0
https://doi.org/10.1007/s11628-017-0359-...
) and capable of promoting disruptive thoughts and actions to generate innovations. The proposed guidelines for step III are presented below: carry out organizational climate survey to identify the level of engagement of the team with the innovation process; identify barriers and facilitators in the process of implementing innovations; reconfigure the environment and create an ecosystem suited to the innovation process; elect the person or sector responsible for the innovation process; define the evaluation rules and criteria (OKRs and KPIs); and, involve and engage the necessary links in the innovation implementation process.

Step IV: IMPLEMENTING INNOVATIONS

In the implementation stage, some precautions need to be taken to ensure success and gain in competitiveness. In this sense, the hospital needs to involve and encourage employees to participate in the innovation process and, if it does not have all the necessary resources internally, it is recommended to form partnerships for the development and implementation, in a collaborative way (Rajkumar & Stentoft, 2017Rajkumar, C., & Stentoft, J. (2017). Harnessing capabilities and practices for sourcing innovation: An exploratory study. Logistics Research, 10(1), 1-21. https://doi.org/10.23773/2017_10
https://doi.org/10.23773/2017_10...
), which helps to reduce risks and uncertainties in the process and facilitates achieving the objectives (Garmann-Johnsen & Eikebrokk, 2014Garmann-Johnsen, N. F., & Eikebrokk, T. R. (2014). Critical Success Factors for Inter-Organizational Process Collaboration in eHealth. In eTELEMED 2014: The Sixth International Conference on eHealth, Telemedicine, and Social Medicine (pp. 217-223). Barcelona, Spain.).

In addition to internal collaborators, there are potential external partners (Johnston & Huggins, 2016Johnston, A., & Huggins, R. (2016). The Spatio-Relational Nature of Urban Innovation Systems: Universities, Knowledge Intensive Business Service Firms, and Collaborative Networks. Journal of Urban Technology, 23(1). https://doi.org/10.1080/10630732.2015.1090192
https://doi.org/10.1080/10630732.2015.10...
) that can be organized in the form of collaborative networks and contribute to the innovation process (Bueno & Balestrin, 2012Bueno, B., & Balestrin, A. (2012). Inovação colaborativa: Uma abordagem aberta no desenvolvimento de novos produtos. Revista de Administração de Empresas, 52(5), 517-530.). Collaboration networks are an efficient strategy for the process of developing and implementing innovations (Mircea et al., 2016Mircea, M., Ghilic-Micu, B., Stoica, M., Sinioros, P. (2016). Inter-organizational performance and business process management in collaborative networks. Economic Computation and Economic Cybernetics Studies and Research, 50(2), 107-122.) and for obtaining competitive advantage (Rajkumar & Stentoft, 2017Rajkumar, C., & Stentoft, J. (2017). Harnessing capabilities and practices for sourcing innovation: An exploratory study. Logistics Research, 10(1), 1-21. https://doi.org/10.23773/2017_10
https://doi.org/10.23773/2017_10...
; Fossas-Olalla et al., 2015Fossas-Olalla, M., Minguela-Rata, B., López-Sánchez, J. I., & Fernández-Menéndez, J. (2015). Product innovation: When should suppliers begin to collaborate? Journal of Business Research, 68(7), 1404-1406. http://doi.org/10.1016/j.jbusres.2015.01.022
http://doi.org/10.1016/j.jbusres.2015.01...
). The proposal presented is so that the process of implementing innovations can be conducted through the following guidelines: structuring a flowchart for the implementation of innovations; involve internal links (managers and employees); include external partners (collaborative networks) when necessary; and implement innovations according to planning.

Step V: MONITOR THE RESULTS

It is in the monitoring stage that the planned results will be assessed. This step must be conducted interactively between the various sectors, to constantly assess the alignment of results with organizational purposes (mission, vision, and values) and, therefore, define the need to initiate innovation processes. This step must be conducted through cycles of constant monitoring (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ), which results will support the identification of new opportunities or innovation needs.

For this reason, the monitoring parameters need to be well defined so that everyone understands how they will be evaluated. In this sense, the hospital must define which will be the key performance indicators - KPIs (Ioan et al., 2012Ioan, B., Nestian, A. S., & Tiţă, S-M. (2012). Relevance of Key Performance Indicators (KPIs) in a Hospital Performance Management Model. Journal of Eastern Europe Research in Business & Economics, 2012, 674169. https://doi.org/10.5171/2012.674169
https://doi.org/10.5171/2012.674169...
; Si et al., 2017Si, S., You, X., Liu, H., & Huang, J. (2017). Identifying Key Performance Indicators for Holistic Hospital Management with a Modified DEMATEL Approach. International Journal of Environmental Research and Public Health, 14(8), 934. https://doi.org/10.3390/ijerph14080934
https://doi.org/10.3390/ijerph14080934...
), individual and collective, that will be used to monitor the achievement of the objectives and key results - OKR (Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) and the frequency with which the measurements will be performed. The proposed guidelines for the monitoring step are presented below: monitor the innovation implementation process; evaluate key performance indicators (KPIs); prepare evaluation reports; and identify the need and new opportunities for innovation. Thus, a summary of the steps and proposed guidelines is presented in Figure 7, below:

Figure 7 -
Steps and proposed guidelines

The preparation of the monitoring stage completes the stages and serves as a basis for identifying new opportunities for innovation, which constitutes a virtuous cycle, capable of assisting management in the process of implementing innovations and, therefore, confirms that it is possible to develop guidelines to assist management in conducting the process of implementing innovations in hospital organizations.

5. FINAL CONSIDERATIONS

The need for innovation in companies arouses interest in researching the literature for its application in the most varied sectors. However, the literature does not present a specific methodology to support the process of implementing innovations in companies. The preparation of this article fulfilled its objective by answering the research question and proposing a set of guidelines to support management during the implementation of innovations in hospital organizations.

As a result, it was possible to structure a sequence of actions, grouped into five stages, capable of supporting management in the process of implementing innovations, from the moment the company arouses to the need to innovate to the effective monitoring of the achievement of the intended objectives with the innovation process, which allowed us to propose a set of guidelines to support management professionals in conducting each of these stages.

The proposed guidelines show the importance of the company arousing to the need to innovate (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.; Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.; Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) and seeking to learn from the perceived opportunities (Teece et al., 1997Teece, D. J., Pisano, G., & Shuen, A. (1997). Dynamic capabilities and strategic management. Strategic Management Journal, 18(7), 509-533.; Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.; Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ) to reconfigure the environment (Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.; Helm & Graf, 2018Helm, R., & Graf, Y. A. (2018). A capabilities-based service development process for industrial manufacturers. International Journal of Knowledge Management Studies, 9(1), 85-102.; Manca et al., 2018Manca, C., Grijalvo, M., Palacios, M., & Kaulio, M. (2018). Collaborative workplaces for innovation in service companies: Barriers and enablers for supporting new ways of working. Service Business, 12, 525-550. https://doi.org/10.1007/s11628-017-0359-0
https://doi.org/10.1007/s11628-017-0359-...
) in order to create an innovation ecosystem that facilitates to implement innovations (Garmann-Johnsen & Eikebrokk, 2014Garmann-Johnsen, N. F., & Eikebrokk, T. R. (2014). Critical Success Factors for Inter-Organizational Process Collaboration in eHealth. In eTELEMED 2014: The Sixth International Conference on eHealth, Telemedicine, and Social Medicine (pp. 217-223). Barcelona, Spain.; Johnston & Huggins, 2016Johnston, A., & Huggins, R. (2016). The Spatio-Relational Nature of Urban Innovation Systems: Universities, Knowledge Intensive Business Service Firms, and Collaborative Networks. Journal of Urban Technology, 23(1). https://doi.org/10.1080/10630732.2015.1090192
https://doi.org/10.1080/10630732.2015.10...
; Rajkumar & Stentoft, 2017Rajkumar, C., & Stentoft, J. (2017). Harnessing capabilities and practices for sourcing innovation: An exploratory study. Logistics Research, 10(1), 1-21. https://doi.org/10.23773/2017_10
https://doi.org/10.23773/2017_10...
), which is able to encourage team participation and allows the company to monitor projected results (Ioan et al., 2012Ioan, B., Nestian, A. S., & Tiţă, S-M. (2012). Relevance of Key Performance Indicators (KPIs) in a Hospital Performance Management Model. Journal of Eastern Europe Research in Business & Economics, 2012, 674169. https://doi.org/10.5171/2012.674169
https://doi.org/10.5171/2012.674169...
; Si et al., 2017Si, S., You, X., Liu, H., & Huang, J. (2017). Identifying Key Performance Indicators for Holistic Hospital Management with a Modified DEMATEL Approach. International Journal of Environmental Research and Public Health, 14(8), 934. https://doi.org/10.3390/ijerph14080934
https://doi.org/10.3390/ijerph14080934...
; Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ).

The article contributed to the literature by presenting empirical contributions in the field of study to fill gaps, such as those presented by Silva (2011Silva, D. O. (2011). Proposta para análise da gestão da inovação em serviços hospitalares: Um estudo no hospital mãe de Deus. [Dissertação de Mestrado]. Universidade do Vale do Rio dos Sinos - São Leopoldo. ), who suggested proposing a methodology for the management of innovation in hospital environments, considering the peculiarities of these environments, and those evidenced by Nyle'n and Holmstro¨m (2015Nyle´n, D., & Holmstro¨m, J. (2015). Digital innovation strategy: A framework for diagnosing and improving digital product and service innovation. Business Horizons, 58(1), 57-67.), who stated that most of the works found analyze the implementation or management of innovation processes related only to the manufacturing sector and, therefore, do not present approaches related to services sector and that, in this case, there is a theoretical gap to be filled. The article also allowed us to corroborate the position of authors such as Engle et al. (2016Engle, R. L, Lopez, E. R., Gormley, K. E., Chan, J. A., Charns, M. P., & Van, D. L. (2016). What roles do middle managers play in implementation of innovative practices? Health Care Management Review, 42(1), 14-27.), on the importance of the manager's roles in the implementation of innovative practices, by Aires et al. (2017Aires, R. W. A., Moreira, F. K., & Freire. P. S. (2017). INDÚSTRIA 4.0: Competências requeridas aos profissionais da quarta revolução industrial. In VII Congresso Internacional de Conhecimento e Inovação, 11 e 12 de setembro de 2017. Foz do Iguaçu, PR, Brasil.), on people's learning in organizations; and added academic and managerial contributions.

The theoretical/academic contributions lie in exploring the theory of innovation and in presenting empirical contributions to fill gaps, highlighting the importance of realizing the need to innovate and reconfigure the environment to take advantage of innovation opportunities (Souza et al., 2014Souza, L. L. C. D., Holanda, R. R., Sousa, S. P., & Costa, E. V. (2014). Estratégias de inovação e crescimento sustentadas por práticas da gestão do conhecimento. Navus - Revista de Gestão e Tecnologia, 3(2), 89-104.), establish indicators to monitor the innovation process (Ioan et al., 2012Ioan, B., Nestian, A. S., & Tiţă, S-M. (2012). Relevance of Key Performance Indicators (KPIs) in a Hospital Performance Management Model. Journal of Eastern Europe Research in Business & Economics, 2012, 674169. https://doi.org/10.5171/2012.674169
https://doi.org/10.5171/2012.674169...
; Si et al., 2017Si, S., You, X., Liu, H., & Huang, J. (2017). Identifying Key Performance Indicators for Holistic Hospital Management with a Modified DEMATEL Approach. International Journal of Environmental Research and Public Health, 14(8), 934. https://doi.org/10.3390/ijerph14080934
https://doi.org/10.3390/ijerph14080934...
; Luna et al., 2017Luna, A. J. H. O., Ribeiro, F. J., Maciel, T. M. M., Farias, I. H., Jr., & Moura, H. P. M. (2017). Uma abordagem para o gerenciamento estratégico ágil em saúde utilizando PES, OKR e MAnGve. Revista Eletrônica Estacio Recife. 3(2). ); and, by proposing guidelines for the implementation of innovation in hospital organizations.

The management contributions highlight the importance of managing the innovation implementation process and present a set of guidelines capable of supporting management at the time of implementing innovations in hospital organizations for each of the five stages that comprise the proposed guidelines.

Although the article was developed with scientific rigor, the fact that the research was carried out in only two hospitals in the northeast region of Brazil stands out as a limiting factor, which may configure characteristics of regionalism and, therefore, as a suggestion for future work, it is recommended to replicate the research in hospitals in other regions in order to corroborate or refute the validity of the proposed guidelines or even suggest complementing the guidelines presented. It is also recommended that the guidelines can be applied in other hospitals to support the development of an empirical method for the implementation of innovations in hospital organizations. In this sense, the practical application of the proposed guidelines can support the development of an empirical method for the implementation of innovations in the service sector. New research can be undertaken to propose methods or models for the implementation of service business innovations.

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Publication Dates

  • Publication in this collection
    10 June 2022
  • Date of issue
    May-Jun 2022

History

  • Received
    12 Sept 2020
  • Reviewed
    29 Mar 2021
  • Accepted
    09 Aug 2021
  • Published
    12 Apr 2022
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