Insights from the Institute for Healthcare Improvement’s 27th National Forum Blog Series – Why we need to reconnect and recharge middle managers

Earlier this month, Knowledge and Intelligence Coordinator Polly Pascoe headed out to the Institute for Healthcare Improvement’s 27th National Forum to learn from experts in the field of quality improvement. This blog is the first in a three-part series that considers how the knowledge and insight gained at the forum can better support the NHS on their journey to becoming the world’s largest learning organisation. This piece focuses on the importance of middle managers in any large-scale cultural shift.

Earlier this year, Jeremy Hunt, Secretary of State for Health, stated that his ambition for the NHS was for it to become the world’s largest learning organisation. This call echoes those in the Berwick Report, as one example, which placed learning in the spotlight as a main concern for health and care in England. To realise this ambition, and for it to be impactful, the NHS must achieve transformational change away from a culture of blame and fear.

When we contemplate the successful implementation of transformational change, we often think of two staff groups: senior leaders who provide shared vision and front-line or administrative staff who implement “bottom-up change”. However, there’s a third group we very rarely consider as integral agents of culture change: middle-managers.

At the Leadership at the Middle: Building Capability mini-course, practitioners from around the world gathered to discuss how we, as change agents in health and care, can tap into the skills and expertise of middle managers to successfully embed improvement and transformation. The model we focused on during the session outlined four main activities of a middle-manager’s role:  work management, work improvement, team capability building and culture shaping.

Polly's Blog

Utilising this model, I have summarised the main points raised in the session and considered how middle managers may hold the key to delivering the NHS as a learning organisation.

  • Middle-managers determine how successfully work is managed

To be successful, organisational learning must be embedded into the day-to-day work of teams. Learning tools such as Before Action Reviews and Retrospect Reviews should be embedded in everyday work, project management processes and recruitment. Without middle-management support and enthusiasm, learning activities can still occur, but it’s unlikely they will be recorded in a useful way that can shared across an organisation and beyond, missing the opportunity to improve patient safety, experience of care and value for money in a transformational manner. Like all other resources, knowledge needs to be managed effectively and middle-managers are positioned perfectly to ensure this occurs, if provided with the correct training and tools to do so.

Managers should be supported to embed learning in day-to-day processes, rather than be required to incorporate it as a ‘nice-to-do’. They should be provided with training and development and be considered learning champions across organisations.

  • Middle-managers drive improvement work forward

Not only do middle-managers hold the key to ensuring services, projects and programmes are successfully managed, but their ‘birds-eye’ view of their team’s work allows them to not only identify areas for improvement, but drive the work forward in the most effective way.  They are also well-positioned to share learning, collaborate and promote cross-departmental and cross-discipline knowledge sharing. This step is vital to support the NHS to progress from maintaining small, isolated pockets of good practice improvement, to developing coherent, department and organisation wide accelerated adoption and spread of improvement.

Managers should not only be concerned with the improvement of their own area, they should be involved in organisational and regional improvement networks, promoting the sharing of learning across disciplines and departments.

  • Middle-managers play a large part in building improvement capability

While many consider a middle-manager’s role to start and stop with the previous two elements, middle managers also play a large part in ‘setting the tone’ for the day-to day working environment for their staff. Their approach can mean the difference between success and failure in hardwiring learning and sustainable improvement into an organisation. One of the ways in which they do this is by managing the work – developing the team habits – and the other is by building capability – ensuring the habits are done well and with confidence. Acknowledging the requirement to learn requires a great deal of bravery and staff must be supported by their managers to not only share their learning, but embed the learning of others in their work. Middle-managers are the key to ensuring staff are able and willing to improve.  They must cultivate an environment where people feel happy and safe to share.  Equally, middle-managers can encourage staff to carry out tasks beyond their role, sharing learning to support other teams and the organisation generally to achieve their objectives.

Managers should be provided with the training and resources to enable them to coach members of their team to become learning experts, modelling behaviours and promoting open and honest environments.

  • Finally, middle-managers are the cultural compass for their team

Accounting for all that’s been said above, the NHS needs to recognise and respect the middle-manager’s leadership capacity, the fourth aspect of the model. While many consider leaders to sit at the highest levels of an organisation, leadership in its most simple form is a ‘process of social influence’.  Ignoring middle-manager’s influence on their staff is to ignore the impact of the potentially damaging subcultures that can arise. While organisations may spend time and money developing vision statements and organisational missions with the intent that their staff will buy into them, middle-managers must be on board, or they can easily act subversively, influencing their staff in negative ways.

Managers should be considered critical cultural actors and not be over-looked when considering large-scale transformational change. Organisations who continue to see middle-managers as simple ‘doers’ and fail to ignite their essential leadership role will also fail when attempting to learn and utilise knowledge effectively.

In conclusion, as the NHS considers how it works towards achieving its learning organisation ambition, my key take-away from the session is that middle managers have a vital role to play.  They will be at the forefront of the NHS being the learning organisation it so desperately needs to become.

Thank you to David Pugh, David Munch, Margo Karsten and Craig Luzinski for hosting such a fantastic session!


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