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Balancing the skills: the need for an improvement pyramid
  1. John Gabbay1,
  2. Andrée le May2,
  3. Con Connell3,
  4. Jonathan H Klein3
  1. 1 Wessex Institute for Health R&D, University of Southampton, Southampton, UK
  2. 2 Faculty of Health Sciences, University of Southampton, Southampton, UK
  3. 3 Faculty of Business and Law, University of Southampton, Southampton, UK
  1. Correspondence to Professor John Gabbay, Wessex Institute for Health R&D, University of Southampton, Southampton, UK; jg3{at}

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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.



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 …

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  • Handling editor Mary Dixon-Woods

  • Contributors The project was initiated and led by JG and AlM. All four authors made substantial contributions to the design of the work and the acquisition, analysis and interpretation of data. JG drafted the paper, but all four had a hand in revising it critically for important intellectual content and gave final approval of the version submitted. All agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.