PURPOSE: To strengthen the middle manager role in a hospital quality improvement (QI) program, with a view to increasing and sustaining organisational QI implementation. DESIGN/METHODOLOGY/APPROACH: Case study based action research project, combining pre- and post-action quantitative and qualitative data collection, relating to a QI program intervention in an Australian metropolitan specialist teaching hospital. A model for enhancing the middle manager role in QI was developed and then implemented as the action over a 12-month period. FINDINGS: Middle manager understanding and ownership of the QI program and organisational QI implementation significantly increased, although their perceived enjoyment of being involved in QI decreased. RESEARCH LIMITATIONS/IMPLICATIONS: This case-study based action research project was limited to one organisation of a specific type - a large specialist metropolitan teaching hospital. The composition of the middle manager group, therefore, is necessarily limited to particular specialties. It is acknowledged that findings from case study and action research methodologies are limited in their generalisability, but assist in the development of knowledge and principles that can be adapted to different settings. PRACTICAL IMPLICATIONS: This QI implementation model can increase levels of organisational QI implementation by effecting a positive change in middle manager attitude to and involvement in QI. ORIGINALITY/VALUE: There are many theories regarding the importance of the middle manager role in QI, but little empirical research into exactly what this role may be and how it may be strengthened. This research adds to the knowledge base, and provides clear steps for achieving increased staff involvement and QI implementation.