Balancing the skills: the need for an improvement pyramid

Improvements in health services require a range of technical skills, but like all complex organisational tasks they also rely on the personal skills and attitudes of the staff carrying out the changes. That much is axiomatic.1 2 3 Less certain, but surely potentially helpful to front-line staff undertaking improvement initiatives, is ascertaining just what might be the right sets of skills needed for different kinds of improvement tasks in varying circumstances.4 5 6 Useful insights into the ways in which a range of organisational circumstances demand such skills were exposed when the Heath Foundation, an independent charity working to improve healthcare quality in the UK, funded our project to help local ‘improvement groups’ learn how to bring about specifically agreed developments, while simultaneously observing how the improvements worked out. By formatively evaluating the processes involved, the intention was to help the Health Foundation promulgate improvement skills more effectively in future. The methods that we used are briefly summarised in box and have been published fully elsewhere along with the details of the sites, participants, processes and outcomes.7 In brief, two National Health Service (NHS) sites were chosen for being exceptionally well primed, due to their apparent excellence in continual quality improvement, to benefit from extra funding, facilitation and expertise aimed at helping them make better use of ‘improvement science’.8 The expectation was that the focus would be on technical skills (such as rapid improvement cycles, process mapping, tailored outcome measures and data analysis), which would be made available as needed through the Health Foundation’s extensive network of improvement experts.Box ### Methods Once we had carried out our orientation interviews and got to know the two organisations, the authors (four senior academics specialising in qualitative health services research and service development) helped each site to identify a …