A qualitative study of the knowledge-brokering role of middle-level managers in service innovation: managing the translation gap in patient safety for older persons’ care

Abstract

Background: Brokering of evidence into service delivery is crucial for patient safety. We study knowledge brokering by ‘hybrid’ middle-level managers (H-MLMs), who hold responsibility for clinical service delivery as well as a managerial role, in the context of falls, medication management and transition, in care of older people. Objectives: Generate insight into processes and structures for brokering of patient safety knowledge (PSK) by H-MLMs. Design: We utilise mixed methods: semistructured interviews, social network analysis, observation, documentary analysis, tracer studies and focus groups. Setting: NHS East and NHS West Midlands. Participants: One hundred and twenty-seven H-MLMs, senior managers and professionals, in three hospitals, and external producers of PSK. Main outcome measures: Which H-MLMs broker what PSK, and why? (1) How do H-MLMs broker PSK? (2) What are contextual features for H-MLM knowledge brokering? (3) How can H-MLMs be enabled to broker PSK more effectively in older persons’ care? Results: Health-care organisations fail to leverage PSK for service improvement. Attempts by H-MLMs to broker PSK downwards or upwards are framed by policy directives and professional/managerial hierarchy. External performance targets and incentives compel H-MLMs in clinical governance to focus upon compliance. This diverts attention from pulling knowledge downwards, or upwards, for service improvement. Lower-status H-MLMs, closer to service delivery, struggle to push endogenous knowledge upwards, because they lack professional and managerial legitimacy. There is a difference between how PSK is brokered within ranks of nurses and doctors, due to differences in hierarchal characteristics. Rather than a ‘broker chain’ upwards and downwards, a ‘broken chain’ ensues, which constrains learning and service improvement. Conclusions: Clinical governance is decoupled from service delivery. Brokering knowledge for service improvement is a ‘peopled’ activity in which H-MLMs are central. Intervention needs to mediate interprofessional and intraprofessional hierarchy, which, combined with compliance pressures, engender a ‘broken’ chain for applying PSK for service improvement, rather than a ‘brokering’ chain. Lower-status H-MLMs need to have their legitimacy and disposition enhanced to broker knowledge for service improvement. More informal ‘social mechanisms’ are required to complement clinical governance for development of a brokering chain. More research is needed to (1) examine why some H-MLMs are more disposed and able than others to broker PSK for service improvement, and (2) understand how knowledge brokering might be enhanced so that exogenous and endogenous knowledge is better fused for service improvement. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Keywords

• qualitative study
• middle-level managers
• knowledge brokering
• patient safety
• older persons’
• care
• service innovation
• patient safety knowledge