Why It Matters
Middle managers need more than clinical or service expertise to meet their organizations’ key strategic and quality improvement objectives.
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Why Middle Managers Are the Key to Quality Improvement Success

By David Munch | Wednesday, November 22, 2017


During my many years of experience in health care, I’ve learned that effective middle managers are critical to sustainable improvement, yet many don’t get the support and development necessary to be successful.  

Let’s consider what often happens in health care. You identify an area that needs improvement. You put together a QI team, and they may achieve improved results, but they don’t last. The QI team is typically not chartered to perform the ongoing monitoring and interventions that sustain performance. So, who is?

It’s the middle managers, supervisors, or “core leaders” who manage care or service delivery on a day-to-day basis. Therefore, a smooth handoff between the improvement team, and those responsible for the maintenance of the new way of doing things is critically important. Without it, you can almost count on even great innovations deteriorating within a year or two.

How to Set Middle Managers Up for Success

Most health care middle managers are promoted from the rank and file, and are very good care or service providers. They’re dedicated, hardworking people who want to do a good job. But they too often lack the training to lead QI teams. So, they end up relying on trial and error. This ends up wasting time and resources, and taking a toll on morale.

Given the importance of this role, shouldn’t health care leaders do all they can to set middle managers up for success? Leaders — especially executive leaders — should do the following to help maximize their managers’ efficacy:

  • Give middle managers protected time to oversee QI. I see so many middle managers who have a wide range of duties. Too often, QI project leadership is then layered on top of a list of responsibilities that is often too long in the first place. Should we be surprised when the QI work then struggles?
  • Invest in developing the skills of middle managers. The executive team should provide the systems and the structures for middle managers to be successful. This includes giving managers the time and resources to learn about QI methods, but also skills like problem solving, communication, time management, and coaching.

If Leaders Aren’t Ready to Invest in Supporting Middle Managers

Some organizations hesitate to invest in staff professional development in the resource-constrained environments in which most hospitals now operate. But an organization pays for poor quality in other ways when they don’t develop the leadership and QI skills of their middle managers.

What is the cost to patients of failed quality improvement efforts? What is the cost of rework? What patient safety, labor, and financial costs do we all have to suffer through because of defects and broken processes?

When I encounter a leader who is reluctant to invest in manager development, I say, “Where are you spending your money now? How much of that is waste? Are you sure can you afford not to invest in your managers’ work?”

If you’re still unsure about the value of investing in the development of your middle managers — or need to convince someone else — start with a small PDSA:  train one team of managers on one unit. With the right training, these managers will show you how leadership and QI skills help to speed the pace of change, sustain improvement, and reduce waste.

Middle managers need more than clinical or service expertise to meet their organizations’ key strategic and improvement objectives. As the liaison between senior leaders and the front lines, the burden falls to them to turn high-level aims into action at the department or unit level. If the executive team won’t support the development of their middle managers, who will?

David Munch, MD, Senior Vice President and Chief Clinical Officer for Healthcare Performance Partners is faculty for IHI’s web-based program, Leading Quality Improvement: Essentials for Managers, starting January 23, 2018.

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