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The purpose of this study is to present a quality improvement approach titled “Picture-Understanding-Action” used in Ireland to enhance the role of healthcare boards in the oversight of healthcare quality and its improvement.

The novel and practical “Picture-Understanding-Action” approach was implemented using the Model for Improvement to iteratively introduce changes across three quality improvement projects. This approach outlines the concepts and activities used at each step to support planning and implementation of processes that allow a board to effectively achieve its role in overseeing and improving quality. This approach matured over three quality improvement projects.

The “Picture” included quantitative and qualitative aspects. The quantitative “Picture” consisted of a quality dashboard/profile of board selected outcome indicators representative of the health system using statistical process control (SPC) charts to focus discussion on real signals of change. The qualitative picture was based on the experience of people who use and work in health services which “people-ised” the numbers. Probing this “Picture” with collective grounding, curiosity and expert training/facilitation developed a shared “Understanding”. This led to “Action(s)” from board members to improve the “Picture” and “Understanding” (feedback action), to ask better questions and make better decisions and recommendations to the executive (feed-forward action). The Model for Improvement, Plan-Do-Study-Act cycles and a co-design approach in design and implementation were key to success.

To the authors’ knowledge, this is the first time a board has undertaken a quality improvement (QI) project to enhance its own processes. It addresses a gap in research by outlining actions that boards can take to improve their oversight of quality of care.

Organizations are confronted with problems and political risks to which they have to respond, presenting a need to develop tools and frames of understanding requisite to do so. In this article, we argue for the necessity of cultivating “political judgment” with a “sense of reality,” especially in the upper echelons of organizations. This article has two objectives: First to highlight how a number of recent interlinked developments within organizational analysis and practice have contributed to weakening judgment and its accompanying “sense of reality.” Second, to (re)introduce some canonical works that, although less in vogue recently, provide both a source of wisdom and frames of understanding that are key to tackling today’s problems. We begin by mapping the context in which the need for the cultivation of political judgment within organizations has arisen: (i) increasing proliferation of political risks and “wicked problems” to which it is expected that organizations adapt and respond; (ii) a wider historical and contemporary context in which the exercise of judgment has been undermined – a result of a combination of economics-inspired styles of theorizing and an associated obsession with metrics. We also explore the nature of “political judgment” and its accompanying “sense of reality” through the work of authors such as Philip Selznick, Max Weber, Chester Barnard, and Isaiah Berlin. We suggest that these authors have a weighty “sense of reality”; are antithetical to “high,” “abstract,” or “axiomatic” theorizing; and have a profound sense of the burden from exercising political judgment in difficult organizational circumstances.