Despite taking advantage of established learning from other industries, quality improvement
initiatives in healthcare may struggle to outperform secular trends. The reasons for this are
rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians
in quality improvement work. In a narrative review of the literature, we argue that this focus
on clinicians, at the relative expense of managerial staff, has proven counterproductive.
Clinical engagement is not a universal challenge; moreover, there is evidence that managers
– particularly middle managers – also have a role to play in quality improvement. Yet
managerial participation in quality improvement interventions is often assumed, rather than
proven. We identify specific factors that influence the coordination of frontline staff and
managers in quality improvement, and integrate these factors into a novel model: the model
of alignment. We use this model to explore the implementation of an interdisciplinary
intervention in a recent trial, describing different participation incentives and barriers for
different staff groups. The extent to which clinical and managerial interests align may be an
important determinant of the ultimate success of quality improvement interventions.