Reinforcing the management contribution
. . . . an ‘enabling environment’ diagnostic
Cranfield Healthcare Management Group
Research Briefing
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How do they manage?
a study of the realities of middle and front line management work in healthcare
David A. Buchanan: May 2011
Pi = f (a x m x c)
Individual performance (Pi) is influenced by a combination of factors, especially ability,
motivation, and context. This is captured by the equation in the heading. In other
words, someone who is very able and highly motivated is unlikely to perform well if the
context, or the environment - the working conditions - do not support their efforts.
Focusing on context, this briefing has two aims. First, to outline the properties of the
enabling environment that reinforces front line and middle management contributions to
clinical and organizational outcomes. Second, to offer a diagnostic, to assess just how
‘enabling’ an organization’s environment is, as a basis for potential reinforcement.
The enabling environment
Our evidence suggests that the organizational environment that supports the contributions of
front line and middle managers in healthcare has the following ten properties:
1 top team communications
2 business intelligence
3 little non-value-adding activity
4 autonomy to innovate
5 organization structures
6 organization norms
clear, consistent, two-way, listening
systems provide appropriate and timely information
streamlined governance and systems
fix problems on own initiative without sign-offs
no silos, information sharing, collaboration
management is valued, risk is taking allowed, no negatives
7 inter-professional working
mutual respect between clinical and managerial staff
8 support services
rapid appropriate advice, action and problem solving
9 teamwork
information sharing, wider impact of decisions considered
10 resources
investing to save, decision rights within budget
There’s nothing surprising about this list of enabling properties. You could call this common
sense. The problem is - yes it makes sense - but evidence suggests that it’s not so common.
The middle and front line management advantage
This isn’t a novel idea. We know about contexts that encourage creativity and innovation, the
diffusion of new ideas, and readiness for change. However, contexts that support front line
and middle management have been neglected. This is surprising because this group are:
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‘ideas practitioners’, bringing innovations into the organization (Davenport, 2003)
major contributors to organization performance (Osterman, 2009)
hit hard by the current crisis - uncertainty and cost cutting (Lane and McGurk, 2009)
creators of the environment that supports their front line staff (Jeon et al. 2010)
central players in both shaping and implementing strategy (Hassan, 2011)
Research has sought to identify factors that enable the strategic role of middle managers
(Mantere, 2008); these relate mainly to top management communications style, relationships,
and expectations, factors that feature as one component of this diagnostic.
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Enabling environment diagnostic
Rate these statements to assess how ‘enabling’ your organization is for front line and middle
managers. This diagnostic can be carried out at different levels - corporate, divisional, team.
Those taking part should have the authority to act on their recommendations. Working as a
group, complete the diagnostic individually before sharing and comparing your responses.
agree
unsure
disagree
1 Our senior management team set clear goals and priorities
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2 Top management listen to ideas from staff at all levels
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3 Our information systems are easy to use
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4 I have the information I need to run my service effectively
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5 Form-filling has become a major part of my role
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6 I often provide the same information to different bodies
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7 I have authority to fix problems within my budget
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8 I can act on my own initiative, without prior sign-offs
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9 Our organization structure encourages information sharing
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10 We have no organizational silos
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11 We focus more on the positives, not the negatives
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12 Management roles and contributions are valued
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13 Managerial and clinical staff trust and respect each other
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14 Clinical-managerial collaborations have brought benefits
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15 HR answer queries and solve problems quickly
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16 Finance are always available with good advice
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17 Staff in my area work together well as a team
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18 Doctors don’t consider how their decisions impact others
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19 We invest to save, spending now to reduce future costs
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20 It’s all about ‘what will it cost?’, and ‘who’s paying?’
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Scoring: give 5 points to each item checked ‘agree’, 3 points to ‘unsure’ and 1 point to
‘disagree’.
Except for items 5, 6, 18 and 20: for those items give 1 point to ‘agree’, 3 points to ‘unsure’
and 5 points to ‘disagree’
This will give you a score from 20 to 100
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Interpretation, prioritization, action
If you are working as a group, combine your scores and calculate the average:
Score 80 to 100
strongly enabling environment; no urgent interventions
Score 50 to 79
gaps in support; some intervention indicated
Score 20 to 49
disabling environment; urgent intervention may be advised
In comparing scores in the group, identify two or three properties which seem to be less
enabling than they could be. Then identify actions to strengthen the environment in those
areas. Finally, cost your recommendations. You may find that most of those actions are costneutral or inexpensive. The potential benefits, however, could be very significant.
Note: This diagnostic offers a structured platform for discussion, prioritization, shared
decision making, and intervention (if necessary). It is neither definitive nor comprehensive.
Other factors will often arise in different settings. Group discussion should identify those.
If you have a view on any these issues, please let us know.
Sources
Davenport, T.H., Prusak, L. and Wilson, H.J. (2003) ‘Who’s bringing you hot ideas and how are you responding?’,
Harvard Business Review, 81(2): 58-64.
Hassan, F. (2011) ‘The frontline advantage’, Harvard Business Review, 89(5): 106-14.
Jeon, Y.-H., Glasgow, N.J., Merlyn, T. and Sansoni, E. (2010) ‘Policy options to improve leadership of middle
managers in the Australian residential aged care setting: a narrative synthesis’, BMC Health Services
Research, 10 (published online): 190-200.
Lane, K. and McGurk, M. (2009) Leaders in the Crisis. Chicago: McKinsey & Company.
Mantere, S. (2008) ‘Role expectations and middle manager strategic agency’, Journal of Management Studies,
45(2): 294-316.
Osterman, P. (2009) The Truth About Middle Managers. Boston, MA: Harvard Business Press.
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The research
This study is based on interviews and focus groups with middle and senior managers at six acute trusts and one
primary care trust. The next stages of the project include a management survey, debriefing groups, and case
studies exploring how changes are managed in the aftermath of serious incidents.
Participating trusts
Bedford Hospital NHS Trust
NHS Bedfordshire Primary Care Trust
Cambridge University Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust
Northampton General Hospital NHS Trust
North Bristol NHS Trust
Whipps Cross University Hospital NHS Trust
Project team
Prof David A. Buchanan (PI)
Dr Charles Wainwright
Prof David Denyer
Dr Clare Kelliher
Ms Cíara Moore
Dr Emma Parry
Dr Colin Pilbeam
Dr Janet Price
Prof Kim Turnbull James
Dr Catherine Bailey
Dr Janice Osbourne
Acknowledgements: The research on which this briefing is based was funded by the National Institute for Health
Research Service Delivery and Organization programme, award number SDO/08/1808/238, ‘How do they
manage?: a study of the realities of middle and front line management work in healthcare’.
Disclaimer: This briefing is based on independent research commissioned by the National Institute for Health
Research. The views expressed are those of the author(s), and not necessarily those of the NHS, the National
Institute for Health Research or the Department of Health.
For further information about this project, contact Jayne Ashley, Project Administrator
T:
01234 751122
E:
J.Ashley@Cranfield.ac.uk
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