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Developing Improvement Capability

Q member Joy Furnival shares - in very accessible form - some of the learning from her PhD on improvement capability.

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To support improved care quality and performance in healthcare, the Health Foundation have repeatedly called for increased focus on the development of improvement capability.  It has also been argued that this development needs to be from ‘within’ healthcare provider organisations and systems.  In addition, a national framework which proposes actions for the building of improvement capability has recently been published in England.  But what do we really mean by improvement capability? How can we assess it? And what changes can we make to develop it?

Our ongoing research suggests that there are different conceptualisations of improvement capability

Our ongoing research suggests that there are different conceptualisations of improvement capability. One perspective suggests improvement capability comprises the improvement skills and abilities of individuals within organisations.  This perspective implies that improvement capability is a set of technical skills which can be taught through training sessions with certification, ‘belts’, and even ISO accreditation.  It suggests that the development and measurement of improvement capability is then relatively simple; counting how many participants have been on a training course or have met the requirements for different levels of competency for a specific group of improvement approaches.  It also facilitates individuals to make judgements of their own personal development needs based on their perceptions about their own improvement capability.  However, this viewpoint seems to us to take little or no account of the wider organisational context for improvement.

An alternative perspective suggests that improvement capability consists of organisational-wide processes and practices of innovation.  That is, rather than being limited to individual skills and abilities, improvement capability is something that incorporates many aspects from across an organisation, including dimensions such as leadership, employee engagement, patient perspectives and other contextual factors as well as individual skills for improvement approaches.  This means that organisations may develop improvement capability through their operating procedures, rituals, culture and behaviours and that the presence of improvement capability is less dependent on specific individuals within organisations.  This type of perspective, informed by the wider research literature of organisational performance, suggests that improvement capability may take time and investment to develop and may also decay or atrophy over time if it is not continuously exercised and updated.

If we accept that there are plural conceptualisations of improvement capability, then there is no ‘one’ right way for its assessment, and its development

However, the wider organisational perspective on improvement capability leads to some challenges in development and assessment.  Our research identified seventy frameworks and instruments that have been used to assess improvement capability, from a range of industries, yet they are diverse and contain many different assessment approaches with little overall consistency in assessment content.  We found four groups, each taking a slightly different conceptualisation:  improvement models, maturity models, change models and governance models.  Different approaches to assessment are also taken, with some using surveys, some interviews and others in-depth case studies of organisations informed by self-assessment.  Further, not one instrument or framework seems to dominate across sectors or geographies and few have been validated.

So, what does all this mean?  If we accept that there are plural conceptualisations of improvement capability, then there is no ‘one’ right way for its assessment, and its development.  But that makes it more difficult for improvement leaders to ensure that they are accomplishing their aims of developing improvement capability.  Therefore pragmatically, when considering how to develop improvement capability, the choice of assessment instrument needs to be contingent on organisational context and patient requirements as well as instrument accuracy.  This will clarify the strengths, risks and blind spots and highlight priorities for development depending on the conceptualisation chosen.  Regulatory agencies for example, may find it useful to compare organisations using an instrument based on a governance model, whereas healthcare provider organisations may find one based on a maturity model more valuable.

In conclusion, to support the development of improvement capability, we need to be clear about what it means and why it is important for improvement capability to be developed.  Further, given the diversity in the perceptions of improvement capability, it is also important to think through whether there is a shared understanding of improvement capability across an organisation or health system, and with stakeholders including patients.  This will inform assessment approaches and associated development strategies.  What do you mean by improvement capability?

Joy Furnival is a Health Foundation PhD Award holder, Generation Q Fellow and Q Community member.  She has worked as Chartered engineer and manager within industry and the NHS.  She is currently completing her PhD at Alliance Manchester Business School, supervised by Professor Kieran Walshe and Professor Ruth Boaden.


  1. Guest

    Just as people become medics through (i) formal training', (ii) through gaining real-world experience within a network of mentor-mentee relationships with experienced 'masters' of diagnosis and treatment (i.e. Consultants) and (iii) with their peers, it strikes me that the model to adopt to develop improvement capability within people and organisations is therefore right under our noses.

    Clinicians are 'human-function' process improvers - we need to create 'human-activity' process improvers - so let's develop people to become these through (i) formal training and (ii) through gaining real-world experience within a network of mentor-mentee relationships with experienced 'masters' - (i.e. Process Improvement experts), and (iii) with their peers . This is how it's done in high-quality product design and manufacturing environments like the car industry, and it's all transferable.

  2. Hi Bruce, thank you for your comment. Your improvement capability development analogy with medics is very interesting. I am curious, though, if there is a broader consensus of conceptualisation of different aspects of medicine (medical capability?), and its assessment than there is of improvement capability and if that plays a role in developing capabilities, (of whichever type). I am really interested in hearing Q community members views.

  3. Guest

    Caroline Poole 5 years, 6 months ago

    Using Michie et al's framework of behaviour change, if we want to see the behaviours of staff, teams, organisations and systems changing, such that they are embedding improvement principles into everything they do, CAPABILITY is just one aspect for consideration. We also need to think about ensuring there is OPPORTUNITY to improve (by redefining the "day job"), and that our mechanisms build MOTIVATION (through recognition and authentic reward).

  4. Guest

    Fiona Greenfield 5 years, 6 months ago

    Hello Joy,

    Thank you for sharing your learning. I found this so useful as it articulated something I have been working with recently. Some times, as I think through my work and face a problem or area for improvement, I find it is easy to fall into the trap of something I refer to as binary thinking i.e. the answer is either this or that. As I learn more about improvement I often experience binary thinking as too limiting. The answer is mostly in a combination of both this and that! So when you talk to improvement capability as not just a curriculum of individual learning to be delivered but also the quality of the organisation, i.e within the culture- the quality of the dialogue between the patients & staff; governance structures and other operating procedures, this rings true. I know there is some ongoing work on a culture survey.

    The challenges we all face in establishing a step change to the improvement capability of organisations we work with may be more effectively addressed if we easily articulate the whole framework of improvement. Developing People - Improving Care is an easy read and very useful. Thank you once again. I enjoyed reading your piece.

  5. Hi Joy,

    Loved reading your views on developing improvement capability. You have really gone under the skin of this important issue. Improvement is often considered separate at individual and organisational levels. We are locally trying to create a common window for routine and improvement work within our acute medicine department. It is important that all NHS staff understand the fundamentals of their job and develop system thinking simultaneously. They should understand the key pillars or domains on which NHS rests and understand the employer's perspective. Be this a student nurse of a foundation year doctor. This will bring not only a top down or bottom up transformation of the system but also an inside out transformation of the individual staff. Leaders need to empower the staff to solve problems by setting up a " cookie trail" and guide them to realise the " joy of work" of discovering the cookie. Nice to see that the Q Lab voters have choses the theme of " Empowering People". Completely agree with Caroline's linkage of capability, opportunity and motivation as of often the last 2 are lacking in various microsystems.

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