Cutting middle managers won’t improve patient care

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Behind every doctor’s visit is a network of middle managers who helped make your appointment possible. But what do they do, exactly?

It’s a question that surfaces regularly in the public sphere. Politicians declare that “cutting bureaucratic bloat” will both reduce costs and improve care for patients. But in a recent Delve podcast interview, two healthcare experts advise caution from decision-makers keen to slash middle management in healthcare.

“Middle managers are the translators,” said Andrea D’addario, a healthcare consultant in Canada’s Northwest Territories and a McGill alum. “We often say they’re the muscle.”

Indeed, they provide valuable support to clinical work. At their best, they can identify efficiencies, processes, and strategic directions that both improve care delivery and free up clinicians to focus on their patients—a core function of middle managers backed up by years of evidence.

“Most strategic ideas actually start from the middle and then spread across the organization,” said Giovanni Radaelli, Associate Professor (Reader) of Operations Management at Warwick University.

And yet, middle managers often find themselves defending their jobs.

Such was the case in a recent study by Radaelli and his co-authors Graeme Currie (Warwick Business School) and Saku Mantere (McGill University). They examined the behaviours of quality managers, a type of middle manager, in 12 Italian hospitals. These managers had responsibilities that overlapped with those of clinicians – which sparked fear that their jobs would one day be deemed unnecessary.

These quality managers thus engaged in various forms of self-advocacy. Some were motivated by career advancement. But the most successful ones had a genuine desire to help.

Radaelli’s findings show that job overlap isn’t always a bad thing. Managers who touch on several areas can help facilitate collaboration between all of them, which can ultimately benefit everyone – especially the patients.

Walking a tightrope

In healthcare environments, quality managers live at the intersection of clinical and executive work. They help execute organizational strategy, develop safety procedures, acquire certifications and accreditations, measure quality performance, and reduce organizational waste – important functions in hospitals. However, some of these responsibilities overlap with those of clinicians, who also play an important role in the quality and safe delivery of care.

In Radaelli’s study, this overlap led to some insecurity among quality managers.

“[They] felt an urgency to prove their value to their organization,” said Radaelli.

They went about it in four different ways.

The first group continued supporting both executives and clinicians upon request. This helped showcase their institutional knowledge, but the core of their work didn’t change as a result. They ultimately played a subordinate role to both groups.

The second cluster of quality managers was more proactive. They identified new areas where they could help, and performed grand gestures to make a good impression on the higher-ups. Relationship-building was central to this approach. They worked across clinical departments to provide institutional support, then highlighted their successes to the executive team. This helped showcase their institutional knowledge but ultimately confined them to a support role for clinicians.

Thirdly, some managers played a brokering role between clinical and executive teams. They used both their executive and clinical knowledge to help align resources for care programmes. This collaborative approach positioned them as integrators. They gained new relevance in multiple areas to help clinicians and executives collaborate more effectively.

And lastly, there were the shrewder operators. These managers strategically worked across the organization to gain deep clinical and executive knowledge. However, instead of using this knowledge to facilitate collaboration, they positioned themselves as gatekeepers between clinicians and executives. They endeared themselves to clinicians by providing valuable institutional support. Then, on the flip side, they offered selective clinical knowledge to executives. The goal was to maintain relevance to both groups without becoming subordinate to either of them.

The right intentions

The quality managers in Radaelli’s study held a unique position in their workplaces. They understood both the needs of clinicians and the operational realities of the organization, which meant they could help align resources with the care goals of clinical teams.

This positionality was important in how quality managers advocated for themselves at work. Some leveraged their position to elevate their importance and advance their careers. These people, however, were quickly found out and sidelined, said Radaelli.

The more successful managers came from a place of help and collaboration, he said. They used their process-oriented mindset to better support clinical work.

“They’re not fighting for power for the sake of power,” said Andrea D’addario.

Rather, they’re advocating for a seat at the table, to lend their expertise to the improvement of patient care. This is especially visible in Canada’s rural north, where D’addario works closely with health organizations of different types. Usually they have small care teams, which means everyone serves multiple functions – and many of them may overlap with each other.

For Radaelli and D’addario, job overlap isn’t necessarily a bad thing. If everyone works on one part of an issue, they can all bring their unique perspectives to the table. And you don’t have to devote a single full-time worker to the task at the expense of something else.

Job overlap may seem like reason to cut jobs. But at the end of the day, everyone brings something valuable to the table, and they’re all working towards the same goal.

“When we think about vocation, we link that rightfully to clinicians,” he said. “But managers do come from a place of ‘we want to help.’”