Middle Managers’ Influence on Healthcare Innovation Implementation

Birken, Lee and Weiner (2012), writing in Implementation Science, propose a theory of how middle managers shape the implementation of healthcare innovations. Their paper draws attention to a group that implementation research has largely ignored, even though middle managers stand between strategy and frontline care.

The problem: a gap between evidence and practice

A large gap persists between evidence of effective care and what patients actually receive. Studies have found that patients receive only about half of recommended care, and disparities in care persist. Part of the explanation is poor implementation: even seemingly simple innovations and quality improvement initiatives often fail to take hold. Research on implementation has focused mainly on physicians and top managers, overlooking middle managers.

The central theory

The authors argue that middle managers can bridge the information gaps that impede implementation. The theory links middle managers’ commitment to an innovation with implementation effectiveness at the organisational level.

Four ways middle managers influence implementation

Diffusing information. Middle managers pass facts about the innovation from top managers to frontline staff and feed information back upwards.

Synthesising information. They integrate and interpret general information so that it becomes relevant to their unit and staff, for example by tailoring external knowledge to their own setting.

Mediating between strategy and daily work. They translate broad strategies into concrete tasks. Because many middle managers have clinical backgrounds, they can connect top-level plans with clinical realities.

Selling the innovation. They justify the change, encourage consistent and effective use of new practices, set norms and model positive attitudes.

Implementation climate and effectiveness

Through these activities, middle managers’ commitment contributes to the implementation climate, that is, employees’ shared perception that using the innovation is expected, supported and rewarded. A strong climate in turn promotes implementation effectiveness, meaning consistent, high-quality and faithful use of the innovation across the organisation.

What shapes middle managers’ role

Implementation policies and practices, such as performance reviews and incentives, influence whether middle managers are able and willing to express their commitment. These policies signal that the organisation values the innovation.

Implications for research and practice

Team-based designs are giving middle managers more responsibility in healthcare organisations, which increases their influence on implementation. Research in other industries shows that this influence can be positive, through strategy realisation and efficiency, or negative, through resistance and withholding information. The authors call for similar empirical research in healthcare. For practice, top managers can strengthen implementation by giving middle managers access to information and resources and by visibly showing their own commitment.

APA Reference:

Birken, S. A., Lee, S. Y. D., & Weiner, B. J. (2012). Uncovering middle managers’ role in healthcare innovation implementation. Implementation Science, 7, 28. https://doi.org/10.1186/1748-5908-7-28