Innovating new models for healthcare differs dramatically from leading established operations or incremental quality improvement (QI). The project to re-create hospitals to deliver less expensive patient-centered care for increasing complex situations is an “adaptive challenge.” Any solution must be newly invented because the knowledge and engineering of the past are not sufficient. What got you here won't get you there. The situation is ambiguous, and the path uncharted. Few address how to lead healthcare innovation. The key leadership needs identified in the management literature (e.g., Hill Brandeau Truelove 2014) challenge traditional medical and nursing practice of experts acting autonomously. These capabilities don’t fit easily with clinical education’s norms. Leaders must inhibit leaping to solutions, truly collaborate across an increasing number of boundaries, value and integrate others’ ideas, and, crucially, be comfortable not knowing. The many current healthcare leadership courses, even those aiming for “transformational leaders,” fail to address these critical capabilities for successful innovation except marginally. For hospitals and care delivery to adopt connected health opportunities, they must work safely and seamlessly in patient care. The care providers must be willing and ready to use them. Yet they disrupt not only workflow but deeply felt professional beliefs and expectations.

Neither the medical literature nor leadership practice identifies clearly the capacities needed for successful innovation. Moreover organizations have singularly focused attention and resources on “top” decision-makers. This overlooks middle managers: their innovation willingness and capacities to implement new processes and roles prove critical to success. This article identifies why and how managers’ vital contributions turn innovations into consistent practice that improve patient outcomes.

This article reviews literature published about US hospitals and clinical care in US-based journals published since the year of Affordable Care Act passage, 2010. The search focused on Pubmed using the keywords that follow plus the author’s familiarity with the management literature on innovation and leadership in other sectors as well as healthcare.

Middle managers implement innovations that produce positive results. At the same time they must ensure on-going patient care remains safe and high quality. They perform multiple, varied roles simultaneously. Key innovation roles for middle and to a lesser extent frontline managers include: - Bridges. - Design reality-testers - Enablers. This includes the roles of Culture creator, motivator, and opportunity creator. - Improvement monitors. The literature on physician leadership, transformational leadership, and leading innovation in healthcare mentions some of these capacities for leaders, yet does so vaguely and inconsistently and with little rationale. Their lists narrow to the task of QI and change management: leading innovation is a riskier, more uncertain and more complex undertaking. Almost none identify middle managers and their capacities as key to the leadership or innovation success.

The specific capabilities that link middle managers to innovation success deserves research attention. Critically healthcare executives must include their managers in their innovation thinking, planning and resource allocation.