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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Readiness Assessment & Developing Project Aims

Part 1: Introduction

Part 2: Key Characteristics of Readiness

Part 3: Assessing Organizational Culture for Change

Part 4: Tools to Support Readiness Assessment

Part 5: Developing and Writing Effective Aim Statement

Part 6: Tools to Support the Development of Aim Statements

Part 7: Related Resources


Part 2: Key Characteristics of Readiness

How do we know if we are ready?

Major QI initiatives can be a challenge for health-care organizations.  It is important that your organization assess its readiness since QI projects may significantly impact your workflow and service delivery.  An assessment of the current environment will help reveal your organization’s chances of successfully implementing changes in practice.  

Organizational QI Program Readiness

A major factor of organizational QI program readiness involves commitment from key decision-makers.  Your organization’s staff should be highly motivated to improve quality and supportive of system wide efforts to expand patient care.  Your organization will improve its QI program readiness by working to build employee morale and stressing the importance of quality improvement.  It may also be valuable to identify leaders within your organization who can help promote QI aims and projects. 

Another factor of organizational readiness includes the financial investment and time commitment needed to support quality improvement.  The readiness assessment will help your organization identify changes that need to be made to invest in its QI project, like reassigning responsibilities, shifting staff schedules and cutting back on costs.  Resource readiness is also a critical factor since additional oversight and data collection tools will be needed to manage quality improvement.  By evaluating existing resources and finances, your organization can ensure that adequate money, staff, IT and other resources are in place to support its QI project during implementation and throughout the entire process.  The resource assessment will help your organization prioritize its QI goals and allocate resources for support.  Lastly, your organization’s QI efforts should coincide with its mission and overarching goals.  QI projects that do not align with system wide goals may confuse employees and communicate disorganization. 

QI Project Readiness

QI project readiness is achieved when your organizational leadership and QI team are fully supportive of and prepared for the QI project.  To measure QI project readiness, you need to assess available resources and evaluate the commitment of organizational leadership and the QI team.  Leadership support is needed because leaders can deliver a strong message that will encourage staff to meet QI goals.  Additionally, they have the authority to allot staff, money and other resources to the project. 

The QI team is essential for project management and should be selected based on the QI aim.  Effective QI teams include individuals with various experiences within your organization. The Institute for Healthcare Improvement recommends that team members include a clinical leader, technical expert, day-to-day leader, and project sponsor.  A clinical leader has the authority to test and implement change and can tackle the issues that may result from the change.  This person has the clinical expertise needed to assess how a proposed change may impact workflow.  A technical expert is critical to the team because this person understands the processes of care.  As an expert on improvement efforts, this individual can help the team identify what needs to be measured and help design the data collection tool.   A day-to-day leader is important for general project management.  This person oversees data collection and should be able to work in close collaboration with physician champions.  A project sponsor is needed because this individual has executive authority to act as a liaison between the team and other departments.   The sponsor can also provide the team with resources needed to support their efforts and help them overcome outstanding challenges.

After designating the QI team, it is important that your organization work with the team to develop a Team Charter  (PDF - 10 pages). A Team Charter will help the team understand the direction it needs to successfully meet the QI aim.

Data collection and measurement tools are needed to track performance and set your organization’s standards for quality improvement.  Before starting the project, your QI team should establish a data collection process and collaborate with staff to develop performance indicators and a plan to test them. 

Health IT is a valuable asset that can assist your QI team with data management.  Health IT can be used to populate data, produce performance reports, and manage other tasks that would otherwise require manual labor.  This saves time and will allow your QI team to focus on other important tasks. The HRSA Health IT website has an assortment of resources to help your organization understand how to use health IT.




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