Middle managers can bridge gap between ward and board

Middle managers can bridge gap between ward and board The NHS doesn't always encourage sharing information across the tiers – but it is essential to improving patient safety.

There is a common theme running through recent reports into patient safety in the NHS: the failure of organisations to pick up and act upon concerns emanating from the front line.

Francis, Berwick, Keogh et al quite rightly identify that breaks in the information chain between day-to-day clinical practice and management structures have led to sub-standard services. However, they don't explore why these breakages happen – or what we can do not just to prevent them, but to actually improve the flow of information.

This is partly because the NHS still doesn't properly understand and appreciate the knowledge-brokering power of what our research describes as "hybrid middle managers". These managers may have different professional backgrounds, are located at different levels of an organisation and carry varying degrees of responsibility. What they all have in common, though, is the ability to act as a two-way mirror; capable not just of assimilating top-down management knowledge but also of translating and transmitting ideas belonging to clinical practice back up into their organisation.

Studies into organisational behaviour indicate that these individuals – who represent around a third of all staff in a traditional hospital, compared to just 3% of pure general managers – have an almost unrivalled ability to share knowledge within and between healthcare organisations. They operate at the front line of service delivery and enjoy credibility and legitimacy within their clinical communities that is not afforded to more generalist managers.

The nature of clinical practice, where knowledge is constantly used alongside individual judgments, means they are well versed in connecting the subjective knowledge used in day-to-day clinical decision-making with the more specific managerial information used in strategic service planning. .

This ability to effectively broker knowledge upwards, downwards and sideways is a hugely valuable commodity. It has the potential to act as the all-important bridge between ward and board. Yet too often in the NHS it is not nurtured and encouraged. There are number of reasons for this.

First, our research has identified a real tension between patient safety knowledge that is pushed into healthcare organisations by outside stakeholders, and knowledge that is generated as a result of frontline clinical experience. Many healthcare organisations end up designing their systems around the requirement to report outwards to commissioners and regulators; yet these systems are not effective for facilitating the transfer of patient safety knowledge to and from the clinical frontline. They also mean that hybrid middle managers with designated roles for patient safety are becoming increasingly management-oriented as pressure mounts to demonstrate compliance to external bodies.

Secondly, it is important to acknowledge that frontline patient safety knowledge is practice-based and often embedded in communities of practitioners. This means it can be difficult to share through conventional clinical governance structures. There is some evidence that financial incentives, such asCommissioning for Quality and Innovation, can help to alleviate this by aligning clinical and managerial service improvement objectives. The creation of specific cross-organisational roles can also help.

Finally, our research found that the extent to which hybrid middle managers engage with the potential of their role is often determined by a combination of their social standing and their overall perception of general management. Hierarchies are widespread in healthcare, and the level of influence hybrid middle managers are able to exert is dependent on a number of personal and professional circumstances.

Inter-professional and intra-professional standing, together with an individual's professional credibility all have a part to play. So too does personal disposition. Their performance is also governed in many cases by their overall perception of general management. Often this view is formulated early in an individual's career, but reluctance to embrace a knowledge-brokering role can be long-lasting.

The evidence suggests that more timely, targeted training around the culture of knowledge brokering in the formative years could help to overcome this reticence. It also points to the importance of finding ways to flatten hierarchical structures wherever possible.

One of the key findings of our research was that in organisations where teams had developed a collective identity, there was effective information sharing that crossed status and inter-disciplinary divides.

In the wake of scandals such as Mid-Staffordshire, all NHS organisations are currently reviewing how they can use frontline clinical experience to shape their strategic thinking. In doing so, they should focus on the vital role that hybrid middle managers have to play in this process.

Graeme Currie is a professor of public management and associate dean at Warwick Business School

 Guardian Professional.