The relationship between middle managers’ commitment to innovation implementation and implementation effectiveness

Evidence is translated into practice when innovations are effectively implemented. An innovation is “an idea, practice, or object that is perceived as new by an individual or another unit of adoption” (Rogers, 2003). For example, the Health Disparities Collaborative (HDC) was a six-year Bureau of Primary Health Care initiative that began in 1999 and was

specifically designed to reduce health disparities in federally qualified health centers (Chin et al., 2004). The HDC was an innovation in health care because it was a distinct, major

initiative that employed strategies unfamiliar to health center employees (Chin et al., 2004). Implementation is “the transition period during which targeted organizational members ideally become increasingly skillful, consistent, and committed in their use of an innovation” (Klein & Sorra, 1996). Implementing the HDC, for instance, involved becoming familiar with and beginning to integrate the chronic care model (Wagner, Austin, & Von Korff, 1996) and Plan-Do-Study-Act cycles into their health centers. For many health centers, this

involved establishing linkages with community resources, improving self-management among patient populations with the disease state of interest (e.g., diabetes), and redesigning care delivery systems to improve care. Innovation implementation, then, refers to the period during which organizational members become proficient in their use of a new practice.

Implementation effectiveness is a multidimensional construct that includes reach

(appropriateness), dose of innovation delivered (consistency), dose of innovation received (consistency), and level of integration (fidelity) (Linnan & Steckler, 2002). In this study, I was particularly interested in the level of integration of an innovation’s components into an organization’s practices (fidelity); the level of integration is indicative of an organization’s

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potential to achieve an innovation’s intended outcomes (Moncher & Prinz, 1991; Rogers, 2003), and I am interested in assessing middle managers’ role in contributing to health care organizations’ potential to achieve the intended outcomes of innovations such as the chronic care model. For example, an organization that has effectively integrated the elements of the chronic care model has the potential to improve chronic disease management (Bodenheimer, Wagner, & Grumbach, 2002a, 2002b). The presence of community linkages, for instance, is one indication that the chronic care model has been effectively implemented in a health care organization; linking patients with community-based resources such as senior centers and exercise programs allows patients to benefit from resources that are not available within many health care organizations.

Commitment refers to attachment to an entity that tends to encourage behaviors intended

to benefit that entity, such as effort toward meeting organizational goals like implementing an innovation intended to improve care for patients with chronic diseases (J. P. Meyer, Stanley, Herscovitch, & Topolnytsky, 2002). Of particular interest in this study is middle managers’ commitment to innovation implementation: To positively influence

implementation effectiveness, middle managers must be compelled to engage in behaviors that promote the effective implementation of innovations. For example, middle managers demonstrated effort toward implementing the HDC in their health centers through regular use of a listserv, virtual classroom, and web page; these are instruments that are intended to provide access to social networks that may promote implementation effectiveness (Wagner et al., 2001). An HDC listserv, for instance, offers middle managers the opportunity to post questions to middle managers in other health centers regarding HDC implementation, share success stories regarding approaches to the HDC that worked in their health centers, and

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offer suggestions to other middle managers regarding how they might solve HDC

implementation-related problems. As such, a middle manager who regularly uses an HDC listserv demonstrates commitment to implementing the HDC because doing so indicates proactivity in identifying solutions to innovation implementation-related problems. Note that the regular use of an HDC listserv, virtual classroom, and web page represent commitment to HDC implementation, not HDC implementation effectiveness; rather, the integration of the HDC’s components (e.g., patient self-management, community linkages, and efficient care delivery systems) into an organization’s practices represent HDC implementation

effectiveness. In contrast, the regular use of an HDC listserv, virtual classroom, and web page are methods that middle managers may use to promote integration of the HDC’s components. For example, a middle manager may use an HDC listserv (commitment to innovation implementation) to solicit ideas about how to empower clinicians to effectively link patients with community-based resources such as senior centers and exercise programs (implementation effectiveness). In this example, HDC listserv use represents a middle manager’s commitment to establishing linkages with community-based resources, and linkages with community-based resources suggest that the HDC has been effectively implemented.

The theory of implementation effectiveness does not explicitly account for middle managers’ role in innovation implementation. As discussed in detail in Chapter 2, however, Klein and colleagues’ (1996, 2001) few references to middle managers suggest that middle managers may influence implementation climate, translating innovations into practice. Some scholars’ research provides insight into how middle managers might influence

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found statistically significant relationships between implementation climate and

implementation effectiveness (Dong et al., 2008; Helfrich, Savitz et al., 2007; Holahan et al., 2004; Klein, 1984; Klein et al., 2001; Osei-Bryson et al., 2008). Many of these scholars concluded that building a supportive implementation climate requires close and frequent interaction with the frontline employees who are tasked with implementation. Since they interact with frontline employees on a daily basis (Uyterhoeven, 1972), middle managers may be in a particularly good position to influence frontline employees’ perceptions of implementation climate.

Indeed, as discussed in detail in Chapter 2, scholars in industries other than health care have identified middle managers as key players in innovation implementation (e.g., Floyd & Wooldridge, 1994; Klein et al., 2001). Specifically, these scholars have suggested that middle managers “sell issues” such as innovation implementation, synthesize information for key employees, create knowledge through social networks, and mediate between strategy and day-to-day activities; in turn, each of these activities may influence implementation effectiveness. Some health services researchers have suggested that implementation

effectiveness may depend on middle managers’ commitment to innovation implementation (Dopson & Fitzgerald, 2006), but they have not empirically studied the relationship between middle managers’ commitment to innovation implementation and implementation

effectiveness in health care organizations; my study is the first to so. My first research question is: What is the relationship between middle managers’ commitment to innovation implementation and implementation effectiveness? My first hypothesis is:

Hypothesis 1: Middle managers’ commitment to innovation implementation is positively related to implementation effectiveness.

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3.2. The relationship between IP&Ps and middle managers’ commitment to innovation