Able to improve? The skills and knowledge NHS front-line staff use to deliver quality improvement: findings from six case studies

3 August 2020

John Gabbay
Andrée le May
David Wright
  • Research, funded by the Health Foundation, into what specific skills and knowledge are needed to deliver successful quality improvement (QI) initiatives in the NHS.
  • Highlighted that improvement relies on a complex interplay of skills; acknowledgement of the importance of generic soft skills; and a sound organisational culture.
  • Through the study of six QI initiatives at three NHS trusts, the research found that improvements on the front line occurred largely through the achievement of six inter-linked sets of ‘socio-organisational functional and facilitative tasks’.

Quality improvement initiatives that do not achieve their intended impact often flounder because they fail to understand the complex contextual, person- and process-related factors involved, and due to a lack of technical QI skills. The 2014 Health Foundation report, Skilled for improvement?, found that successful QI initiatives rely on a pyramid of three skill sets – technical, soft and learning – built on a sound organisational foundation.

This research set out to uncover which improvement skills matter most, and when and why they are important; what factors help or impede practitioners’ use of their improvement skills; and how and why QI teams overcome barriers. 

The researchers worked with three acute NHS trusts, with different CQC ratings, over 14 months. Two QI initiatives were chosen from each of the trusts. Almost 200 interviews, with mainly front-line staff, were carried out.

The research confirmed that improvement does rely on technical, soft and learning skills, but showed that the pyramid is more complicated than suggested in the earlier report. Front-line staff were found to use a limited range of technical and learning skills, but did use countless generic soft skills.

Where improvement initiatives were successful, several fundamental features of the organisational culture were found, including: establishing respectful critical dialogue; constructively confronting failure; resourcing and rewarding good suggestions; and ensuring efficient structures and processes.

The researchers found that improvements on the front line occurred largely through the achievement of six inter-linked sets of ‘socio-organisational functional and facilitative tasks (SOFFTs)’:

  • Adopting and promulgating the appropriate style and tone through, for example, ensuring a blame-free, nurturing, open environment.
  • Managing the QI roller-coaster through, for example, avoiding ‘initiativitis’ and effectively co-ordinating improvement.
  • Getting the problem and solution right by understanding what is wrong and why, and co-designing improvement work.
  • Communicating the right message to the right people through, for example, framing it correctly.
  • Enabling learning to occur through creating a local learning culture and growing the necessary QI skills.
  • Contextualising experience by adapting prior experiential learning and transforming the original improvement to match the context.

Read the summary report:


For more information about this research please contact Bryan Jones, Improvement Fellow at the Health Foundation,

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