New Perspective
How Middle Managers Can Influence Innovation Implementation
by Sarah Birken, MSPH, PhD, Postdoctoral Fellow in the Cancer Control Education Program at the Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
How Middle Managers Can Influence Innovation Implementation
By Sarah Birken, MSPH, PhD Introduction Studies of innovation implementation in community health centers have shown that middle managers play an important role by communicating with senior management and helping frontline staff achieve desired changes.1 Middle managers are employees who are supervised by an organization’s senior managers and who in turn supervise frontline employees such as clinicians, mid-level providers, medical records staff, and front desk staff. Because of their strategic position between senior managers and frontline staff, middle managers can bridge information gaps that might otherwise impede innovation implementation. Middle managers can give frontline staff information about implementation, make the information relevant to them, and provide them the tools necessary to promote consistent implementation. For example, an implementation effort aimed at getting providers to conduct medication reconciliation is effective if all targeted providers follow the specified process during applicable clinical encounters. Senior managers set the stage for effective innovation implementation by hiring proactive middle managers and contributing to an organizational climate in which proactivity is expected, supported, and rewarded. When middle managers communicate about the types of support that will help them implement innovations effectively, senior managers can demonstrate their support by taking the following steps:
By serving as information brokers, middle managers help advance the implementation of an innovation. Implementation is the transition period during which employees ideally become more skilled, consistent, and committed to using an innovation.2 The key role of middle managers in the implementation process has been observed in studies of the Health Resources and Services Administration’s (HRSA's) Health Disparities Collaboratives (HDC). The HDC guided community health centers to improve chronic disease care by developing organizational infrastructure, leadership, and staff expertise through implementing processes of continuous learning, change management, and quality improvement. The HDC was an ideal innovation environment for our research team to study the middle manager’s role in the implementation process. HDC implementation was effective when participating health centers used the six components of the Chronic Care Model: community resources, self-management support, delivery system design, clinical information systems, decision support, and health care organization. How middle managers promoted HDC implementation—diffusing information, synthesizing information, mediating between day-to-day activities and organizational strategy, and promoting the value of innovation implementation to senior managers and frontline staff3—is described below with relevant examples:
The commitment level of middle managers in the HDC studies was assessed based on their level of engagement in activities that went beyond fulfilling their basic job requirements. These extra activities included changing health center operations, soliciting grant funding, and developing and maintaining high-quality, timely patient data registries. Middle managers were particularly influential in promoting effective implementation when they displayed a positive attitude. In contrast to low-commitment middle managers, high-commitment middle managers persevered in these activities until they achieved the desired results. High-commitment middle managers also were proactive in creating effective solutions to problems that frustrated low-commitment middle managers. For example, developing ways to link patients with diabetes to community resources, such as companies that offered discounted orthotic shoes, allowed a high-commitment middle manager to overcome the health center’s limited financial resources. Middle managers also acted as liaisons between their health centers and external organizations. For example, developing patient registries involved submitting reports to HRSA’s Bureau of Primary Health Care. Middle managers who were proactive in ensuring patient data quality and timeliness promoted effective implementation of the HDC in their health centers. About Sarah Birken, MSPH, PhD Dr. Birken is a postdoctoral fellow in the Cancer Control Education Program at the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill. Her research focuses on the dissemination and implementation of innovations in cancer care. Currently, she is studying the dissemination and implementation of survivorship care plans in U.S. cancer programs. She has won awards for distinguished scholarly achievement, such as the Academy of Management’s Health Care Management Division Best Paper Based on a Dissertation. Dr. Birken has several peer-reviewed empirical and theoretical publications in highly ranked health services journals. Disclosure Statement: Dr. Sarah Birken reported that her institution received grant funding from AHRQ, which funded her doctoral dissertation on the role of middle managers in innovation implementation. Her institution also received grant funding from the National Cancer Institute that supported her postdoctoral fellowship, which enabled her to write several articles on the role of middle managers in innovation implementation. Footnotes
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