Despite my having many years of management experience, I'm not sure what you mean by "the level manager".  Can you clarify that?  Although I do not fully understand the question, I would note that quality improvement efforts seem to work best when multiple levels of organization are involved.  This was nicely stated in a 2001 paper by Ewan Ferlie and Stephen Shortell that I'm attaching.

I am in the same school with Stephen waiting for your clarification. Similarly, I want to note that quality can be operationalized as an organizational policy, strategy and or philosophy with a focus to satisfy clients/customers. in this context all managers whatever their level within the organisation, have no choice but to ensure high level quality is attained. 

Hi respondents to my question, thank you for the prompt response to my question. I thank Stephen for the paper that you shared. What I meant by "the level manager" is that at any health service delivery point there is a manager overseeing key processes to ensure quality care. Take for instance, the ward in-charge has to ensure that she provides technical guidance and plays the administrative role in order key processes to happen. I concur with Stephen since a doctor needing a pair of gloves to work on a patient will certainly have to rely on the line ministries to access the gloves for his patient and these are at multiple levels. I also do concur with Chris for the fact that all QI efforts are geared towards satisfying both the internal and external clients. i hope i have answered both of your concerns.

Thanks.  I understand what you are saying; and I think you will find that in any instance where staff is interested in doing something that will improve quality of care, it is very important that the manager be on board.  Even when a project seems to be internal to a unit (delivery point), sustaining the improvement usually requires buy-in of the manager.  And, often, there is some part of the improvement process that requires cooperation, possibly even collaboration, of another unit, in which case having the manager on board is essential.

Shortly after sending my answer to you, I had a chat from a workmate from the field and she shared concerns of one Medical Superintendent who wasn't engaged ,by the district health QI team, in departmental QI activities and yet he oversees all these departments. I gave guidance to them that the hospital boss should be brought on board as per the MOH recommendations. i hope this will help the hospital MS buy-in and support ongoing QI in the facilities.

Ibrahim, that is the point. Quality Improvement must start from the top as a policy engrained in the hospital's mission and vision operationalize by SOPs, guideline manuals, and technical operation standards at lower levels. This may not be explicit but implicit at  this higher point. That is why a QIT may come from the national or regional office but should never bypass the hospital boss and deputies, if they want their efforts to bear fruits.  I have been involved in this kind of thing for years. The Boss does not need the details required at operation levels. He must understand the intentions and accept it to the level of ownership.

Then comes in the mid-level managers who supervise the first level managers you are calling "level managers", who are the actual implementers and superiors of quality improvement strategies and activities at the client interaction levels on daily and hourly basis. Their failure is the failure by the organization to its customers. They require detailed training in all aspects of managing for quality improvement including standard setting, statistical analysis and evaluating, reporting, problem solving,  etc.  

Hi Chris and Stephen, I'm indebted to you for the contributions that are being shared in this online exchange. I wonder what would be the best way to build the level manager's will to catalyze the improvement efforts at all the multiple levels.

Ibrahim, the question is whether the manager is actively opposed to quality improvement or to a particular QI project, neutral, or generally in favor but not very knowledgeable.  It is sort of like the Prochaska stages of change.  Ideally the manager is at least "generally in favor".  If neutral, then one has to point out the advantages of improvement - and perhaps give the manager something to read or possibly a TED-talk (there are a couple that are OK).  If the manager is negative/opposed, then one can try to explore why; but ultimately the manager has to change his/her opinion; and whether or how one can help the manager change opinion depends upon a lot of local considerations, e.g., relative power of the manager vs. the staff, whether their is a quid pro quo, etc, etc.

My thought are that what you are creating is a culture shift.  For that to happen the managers at every level must create a culture for improvement and safety.  This involves creating a learning culture that but begin at the front line and must include everyone.  What you want to strive for is "ownership" not buy-in.  Buy-in is a very superficial agreement, ownership is just that they own the process and the changes.  It is a much deeper level of engagement.  Creating a learning culture is what you will what to move toward, where everyone one from clincial staff to the housekeeping staff participate in the improvement of care,  they own the process and outcomes.  The patients are important to them.  Suggest looking at the text, "Knowledge for Action" by Chris Argyris.  Also including some Dartmouth articles that might help you, they are older but the theories still apply, they are the core of what most are doing for system change.  Also look at what IHI.org is doing about system change.

Dear Ms.Diana Luan, thank you so much for your technical in-put and reference materials that you shared. I'll shortly share my insight of what you shared and in the customized context what is applicable here on the ground. I have also had challenges addressing situations where the level manager has no control and influence over the superior manager who is also dependent on the big manager, say a relevant ministry! Take for instance, a nursing officer, through her local bosses, timely places an order for consumables because she has to use them to give a safe injection but the ministry says there is no money and they can't priorities to allow this slot of request and yet the demand at grass-root still remains high. In such situations, the patient suffers the consequences and ministry through the line departments raises concern of the increasing injection abscesses at the PHC level!

However you engage in to improve the quality of care you must include the individuals above the level manager.  They must all be part of the engagement team to examine how they might improve the process of obtaining supplies for the clincial level.  It is important to have data when you present for request for resources.  Suggest you provide statistics on the population you serve and the process of care you provide.  Armed with data you can make a stronger argument for requests.  I am attaching the outpatient workbook that was developed at Dartmouth College and that I have used in working with clinical sites.  It may not be completely usedful for you, but some part may and you can adapt the materials to fit your needs.

Ibrahim, I understand your challenge - a tall organization with a along chain of leaders.  That is common in a centralized government system. Many people people working in such a system suffer from similar challenges. Things are simpler but not necessarily better in private institutions.

The level leader suffers from being the most junior leader along the chain. As such, the senor leaders may not take him/her suggestions seriously, despite the fact that she is the one managing the results the organization depends on. she gets the blame  on poor results even when the cause is from high up. One challenge in a tall organization is that the suggestions from the bottom are modified as they go up the decision making authority. By the time they reach there the information is may not be the same. Yet the information coming down can be magnified such that by time it reaches down it is too heavy, too weighty and threatening on the level manager.

How do you handle this? It is the level manager who produces high quality results that are cost effective. Learn to lead from behind. Depend on those you lead. Learn to manage your boss. Data speaks volume. Records save leaders from the jaws of lions - keep records, document all your actions and plans. Make use of every opportunity that presents itself to communicate evidence based "truth". I have done this many times and it worked for me well over the years on my journey from the bottom to the top.     

Happy new year Chris. It is not proper for a person of my kind to have taken all this long to reply you. Thank you for sharing your openness about the subject matter and I liked your guidance on use of records to capture one's actions. Might you be having any common tool that one would use to give feedback to the high authority?