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How Middle Managers Can Influence Innovation Implementation | AHRQ Innovations Exchange

How Middle Managers Can Influence Innovation Implementation | AHRQ Innovations Exchange

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How Middle Managers Can Influence Innovation Implementation

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

AHRQ Health Care Innovations

How Middle Managers Can Influence Innovation Implementation

By Sarah Birken, MSPH, PhD

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:

  • Convey to middle managers that an innovation is an organizational priority
  • Provide the infrastructure to facilitate innovation implementation (such as access to human, financial, and training resources and the local social network)
  • Create policies and procedures such as performance reviews and incentives for innovation implementation
Middle Managers as Information Brokers 

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:
  • Diffusing information. Middle managers gave frontline staff important information about innovation implementation and kept senior managers informed of implementation progress. For example, middle managers who oversaw HDC implementation were tasked with explaining to providers that the HDC would require developing a patient registry. When providers resisted completing the flow sheets used to gather data for the patient registry, middle managers informed senior managers of the providers’ resistance4 and enabled senior managers to address this obstacle to HDC implementation.
  • Synthesizing information. By integrating and interpreting facts, middle managers made general information about innovation implementation relevant to their organizations and employees. For some middle managers who oversaw HDC implementation, synthesizing information involved significant changes to their health center’s operations. To effectively implement the HDC, receptionists implemented a new scheduling system that provided more preventive visits, appointment reminder calls, and letters; medical assistants ensured that new patient flow sheets were included in patients’ health records; providers changed the way they interacted with patients, including actively engaging patients in their own self-management; and lab technicians responded to increased demands for more regular testing.5
  • Mediating between day-to-day activities and organizational strategy. By identifying tasks required for implementing innovations and providing context from a strategic perspective, middle managers gave employees the information that they needed to implement innovations. For example, middle managers who oversaw HDC implementation explained to employees how appointment systems used to schedule chronic care followup appointments influence care coordination and patient outcomes. Middle managers also described the role of patient data registries in developing useful clinical information systems for analysis and reporting.5
  • Influencing innovation implementation. When middle managers justify innovation implementation to employees, it encourages them to use innovations consistently and proficiently. For example, HDC middle managers explained that using appointment systems to schedule chronic care followup appointments would minimize the need for episodic acute care, improve patient outcomes, and facilitate appointment scheduling. Many middle managers reported trying to promote HDC implementation to resistant employees, which reflected the managers’ commitment to the implementation process. By monitoring their own negative reactions about HDC implementation, middle managers encouraged staff to maintain a positive attitude toward the implementation process.5
Importance of Commitment Level to Effective Innovation Implementation

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.


1 Birken SA, Lee SY, Weiner BJ, et al. From strategy to action: how top managers’ support increases middle managers’ commitment to innovation implementation in health care organizations. Health Care Manage Rev. 2014 Feb 21 [Epub ahead of print]. [PubMed]
2 Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.
3 Birken SA, Lee SY, Weiner BJ. Uncovering middle managers’ role in healthcare innovation implementation. Implement Sci. 2012;7:28. [PubMed]
4 Birken SA. Where the rubber meets the road: a mixed-method study of middle managers’ role in innovation implementation in health care organizations. PhD dissertation. Chapel Hill: University of North Carolina, Department of Health Policy and Management; 2011.
5 Birken SA, Lee SY, Weiner BJ, et al. Improving the effectiveness of health care innovation implementation: middle managers as change agents. Med Care Res Rev. 2013;70(1):29-45. [PubMed]

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