Mid-level Leaders

Individuals with a moderate level of authority, including leaders supervised by a high-level leader and who supervise others.

The updated CFIR divides formal leadership roles into two levels (see below). Commitment of individuals (see also Characteristics: Motivation) in formal leadership roles at multiple levels is a significant and frequently assessed determinant of implementation outcomes (Kirk et al., 2015). Commitment, involvement, and accountability (see also Characteristics: Motivation and Opportunity) of leaders and managers have a significant influence on the success of implementation (Klein et al., 2001; Meyers et al., 1999; VanDeusen Lukas et al., 2007). Anything less than wholehearted support from leaders, dooms implementation to failure (Repenning, 2002). Leadership support in terms of commitment and active interest leads to a stronger implementation climate which is, in turn, related to implementation effectiveness; this association is strengthened, the more users are required to work together to implement (Helfrich, Weiner, et al., 2007; Klein et al., 2001). Committed leaders have managerial patience (taking a long-term view rather than short-term) to allow time for the oft-inevitable reduction in productivity until the innovation takes hold (Klein et al., 2001) and can be important conduits to help persuade other individuals via interpersonal channels and by modeling norms (see Culture: Learning-Centeredness) associated with implementing an innovation (Leeman et al., 2007). Leaders are important for their ability to network (see also Relational Connections) and negotiate for resources (see also Available Resources), allocating time (see also Characteristics: Opportunity) and priority (see also Relative Priority).

Mid-level managers are a key link between strategic decisions from High-level Leaders and the people who must execute implementation and accomplish delivery of the innovation (S. Birken et al., 2018; S. A. Birken & Currie, 2021). Mid-level Leaders can include clinical leaders who often lead implementation efforts (Ilott et al., 2012) and/or direct supervisors of Implementation Leads and others involved in implementation. Mid-level leaders are benefited by having skills in mediating between high-level strategy in the Inner Setting and day-to-day activities and in diffusing, selling, and synthesizing information related to the innovation and its implementation (see Capability) (S. Birken et al., 2018). These leaders are more likely to support implementation if they believe that doing so will promote their own Inner Setting goals (see also Inner Setting: Mission Alignment) and if they feel involved in discussions about the implementation (Meyers et al., 1999).

Qualitative coding guidelines that are aligned with the Updated CFIR will be added in the future.

See High-level Leaders for information on potential quantitative measures.

As we become aware of measures, we will post them here. Please contact us with updates.

Birken, S., Clary, A., Tabriz, A. A., Turner, K., Meza, R., Zizzi, A., Larson, M., Walker, J., & Charns, M. (2018). Middle managers’ role in implementing evidence-based practices in healthcare: A systematic review. Implementation Science, 13(1), 149. https://doi.org/10.1186/s13012-018-0843-5.

Birken, S. A., & Currie, G. (2021). Using organization theory to position middle-level managers as agents of evidence-based practice implementation. Implementation Science, 16(1), 37. https://doi.org/10.1186/s13012-021-01106-2.

Helfrich, C. D., Weiner, B. J., McKinney, M. M., & Minasian, L. (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Med Care Res Rev, 64(3), 279–303.

Ilott, I., Gerrish, K., Booth, A., & Field, B. (2012). Testing the Consolidated Framework for Implementation Research on health care innovations from South Yorkshire: Testing the CFIR on health care innovations. Journal of Evaluation in Clinical Practice, n/a-n/a. https://doi.org/10.1111/j.1365-2753.2012.01876.x.

Kirk, M. A., Kelley, C., Yankey, N., Birken, S. A., Abadie, B., & Damschroder, L. (2015). A systematic review of the use of the Consolidated Framework for Implementation Research. Implementation Science, 11(1), 72. https://doi.org/10.1186/s13012-016-0437-z.

Klein, K. J., Conn, A. B., & Sorra, J. S. (2001). Implementing computerized technology: An organizational analysis. Journal of Applied Psychology, 86(5), 811–824.

Leeman, J., Baernholdt, M., & Sandelowski, M. (2007). Developing a theory-based taxonomy of methods for implementing change in practice. J Adv Nurs, 58(2), 191–200.

Meyers, P. W., Sivakumar, K., & Nakata, C. (1999). Implementation of Industrial Process Innovations: Factors, Effects, and Marketing Implications. Journal of Product Innovation Management, 16(3), 295–311. https://doi.org/10.1111/1540-5885.1630295.

Repenning, N. P. (2002). A Simulation-Based Approach to Understanding the Dynamics of Innovation Implementation. Organization Science, 13(2), 109–127. https://doi.org/10.1287/orsc.

VanDeusen Lukas, C., Holmes, S. K., Cohen, A. B., Restuccia, J., Cramer, I. E., Shwartz, M., & Charns, M. P. (2007). Transformational change in health care systems: An organizational model. Health Care Management Review, 32(4), 309–320. https://doi.org/10.1097/01.HMR.0000296785.29718.5d.