How do they manage?
the realities of middle management work in healthcare
Focusing on hospital middle management roles, this project, ending in June 2012, was funded by the National Institute for Health Research, Health Services and Delivery Research programme.
The project addressed three questions. First, how are middle management roles in acute care settings changing, and what are the implications of these developments? Second, how are changes managed following serious incidents, where recommendations from investigations are not always acted upon? Third, how are clinical and organizational outcomes influenced by management practice, and what properties should an ‘enabling environment’ possess in order to support those contributions?
Data were gathered from 1,200 managers in six trusts through interviews, focus groups, management briefings, a survey with 600 responses, and serious incident case studies. Evidence from hospital workforce information offices show that the management function is widely distributed, with over 30 per cent of hospital staff holding either full time management posts, or ‘hybrid’ roles combining managerial with clinical responsibilities. Hybrids outnumber full time managers by four to one, but most only limited management training, and some do not consider themselves to be managers.
Contrary to the unflattering stereotype, middle managers are deeply committed, but face increasing workloads with reduced resources, creating ‘extreme jobs’, with long hours, high intensity and fast pace. Such roles can be rewarding, but carry implications for work-life balance and stress.
Despite these pressures, management contributions to clinical and organizational outcomes are many, and include maintaining day-to-day performance, firefighting, ensuring a patient experience focus in decision making, translating ideas into working initiatives, identifying and ‘selling’ new ideas, facilitating change, troubleshooting, leveraging targets to improve performance, process and pathway redesign, developing infrastructure (IT, equipment, estate), developing others, and managing external partnerships. Actions required to maintain an enabling environment to support those contributions would involve individual, divisional, and organizational steps, most of which would be cost neutral.
There are many barriers to the implementation of change following serious incidents. These barriers relate to the complex causes of most incidents, the difficulties in establishing and agreeing appropriate action plans, and the problems of implementing ‘defensive’ change agendas. We conclude that the management of serious incidents would be strengthened by adding a change management perspective to the current organizational learning focus, by complementing root cause and timeline analysis methods with ‘mess mapping’ processes, and by exploring opportunities to introduce systemic changes and high reliability methods in addition to fixing the root causes of individual incidents.
In the current climate of deepening austerity and more radical change, middle management capabilities that are at a premium include political skills, resilience, developing interprofessional collaboration, addressing ‘wicked problems’, performance management, and financial skills.
David A. Buchanan: May 2012