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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 3: Assessing Organizational Culture for Change

How do I build a culture for improvement?

Organizational culture is the shared beliefs, experiences, and expectations of people within an organization.  An organizational culture that embraces a non-punitive, mutually supportive environment is needed to drive QI initiatives.  Staff members who share the same vision as the organization are more willing to adapt to change.  If your organization’s existing culture does not support change, work must be done to transform employees’ perception before moving forward with QI plans.  Your organization’s leadership team should work to build a culture that promotes learning, effective teamwork and patient-centered care. 

As a result, staff will recognize that quality is valuable to the organization.  Be sure to engage clinicians and staff with system-wide goals at the beginning stages of quality improvement.  By gearing the mission towards quality improvement; aligning QI aims with system wide goals; and making staff aware of current performance, your organization will set the tone for quality improvement.  

Your QI team will also set the tone for change.  The team should include different types of providers—clinicians, pharmacists, health educators, health information management staff, patient advocates—depending on the QI aim.  Various providers can offer insight on different aspects of quality improvement that are easy to overlook.  Once the QI team is formed, it should specify the roles of each member.  In general, successful QI teams:

  • Include the appropriate individuals and expertise;
  • Establish well-defined team processes;
  • Identify team leaders to manage certain tasks;
  • Align all work to meet the QI aim; and,
  • Gather all required resources needed to implement the QI project.

By forming effective teams and motivating leaders to incorporate quality improvement into the mission and core values, your organization will build a culture that supports quality improvement.

How do we address other prerequisites for QI?

It is important for everyone within your organization to accept accountability for quality improvement.  A culture that embraces organizational accountability is more likely to successfully improve the quality of patient care.  Your organization can build accountability by motivating clinicians and staff to meet QI aims.  By no means should accountability be understood as a form of punishment.  In Applying High Reliability Principles, (PPT - 2.46MB) several tips are provided to help organizations build staff accountability.  These tips recommend that organizations address existing problems in workflow; design easy-to-follow processes for staff; and, provide constructive feedback to staff.

Before starting QI projects, your organization must define roles and responsibilities of key individuals who will drive the QI aims.  Clinicians play an important role because they are the primary decision makers of patient care. Clinical staff members are also crucial as they provide routine care to patients. Administrative staff members are also critical to QI initiatives.  Some of their efforts may relate to health information management, for example.   Individuals within your organization who are responsible for driving patient safety initiatives should also take part in QI projects. Organizational leaders are also important for quality improvement since they communicate QI expectations to staff.  By delineating roles and assigning clear tasks for all staff, your organization can make quality improvement a shared responsibility.  Additionally, your QI projects will be organized and easier to implement if tasks are evenly divided throughout the organization.

In addition to accountability, organizations need to overcome staff resistance which can prove to be a major barrier to quality improvement.  Staff may resist a QI project if they believe it will slow operations and increase workload.  Gaining buy-in will require your organization to embrace a learning culture where everyone works in close collaboration to develop QI aims and projects.  Your organization must also have ample resources in place to support projects.  If staff participate in project development and perceive organizational support, they are more likely to accept the QI project.




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