Perhaps none of the questions is more important or fundamental than “What are we trying to accomplish?” By answering this question, we have seen teams transform their work. They’ve used this question to develop a shared understanding of the outcome they hope to achieve and to determine their system (or population) of focus.
Yet, we often see teams struggle with the output of this question — the aim statement. In some cases, a misguided aim causes teams to lose focus on what really matters, introduces unnecessary delays, and diminishes their joy in work.
As we reflected on these challenges, we identified some common misunderstandings that lead aim statements to go astray. In most cases, it is the art of improvement — knowing which aspects of improvement to apply in which contexts — that teams need to consider when developing their improvement aims.
Myth #1: The aim must come first.
Most people assume that one needs to answer the three Model for Improvement questions in order, starting with “What are we trying to accomplish?” (which focuses on aim setting). In reality, you can begin an improvement effort by addressing the three questions in any order. You may, for example, start with a change idea or a measure to improve and work your way backward to the aim.
For example, one team with whom we worked developed the following aim: “Reduce patient paperwork by 50 percent by September 30.”
In further conversations with this team, we learned that the desire to reduce paperwork stemmed from complaints — from patients, about giving the same information multiple times; from clinicians, about workflow delays as patients filled out forms; and from administrative staff, about the workflow burden.
By urging the team to determine the real reason why they wanted to reduce paperwork, they were able to articulate their true aim. That is, they wanted to reduce paperwork (the change, or answer to the third question) to improve patient flow through the clinic, reduce time processing paperwork, and improve patient and provider satisfaction. Though the team may have started out by focusing on paperwork, it is important not to confuse the change with the aim — the team could reduce paperwork without achieving the real goal of better flow and satisfaction.
Myth #2: Aims must be “how much, by when” statements.
In most cases, the clarity and pace created by a “how much, by when” aim statement is very useful. A deadline for progress creates urgency and avoids the trap of the never-ending improvement project.
However, there are some instances in which that level of specificity for the answer to “What are we trying to accomplish?” may not be appropriate. Here are three examples:
- An organization with a culture in which not achieving the aim might be deflating for staff morale (at best) and punitive (at worst)
- An improvement effort where the purpose of improvement is not easily described by one outcome measure (e.g., improving patient experience instead of improving HCHAPS)
- A complex initiative that requires movement on a diverse set of outcome measures (e.g., the Triple Aim)
The art of writing an effective aim statement is finding a focus that inspires hearts and minds, provokes action, provides guidance, and sets expectations while avoiding unintended consequences (e.g., gaming the system to achieve the goal).
Myth #3: The aim is the start of understanding the system.
Ideally, the quality improvement infrastructure within an organization incorporates all three interrelated components of the Juran Trilogy — quality planning, quality improvement, and quality control. Without first paying attention to all three components, improvement teams may find it difficult to more fully understand the current system before they jump into aim development and start to improve the system. A thorough understanding of the system might include identifying the problem they’re trying to solve, measuring baseline performance, understanding the gaps in the current system through data and firsthand observation, or running some initial testing (PDSA cycles) to learn. While it is important to understand the current system before diving in to improve it, be careful of analysis paralysis. Set a limited amount of time for the team to do the exploration before moving on to improvement.
Essential Elements of a Good Aim Statement
Now that we’ve debunked some myths, let’s be clear about what goes into a good aim statement. Whenever possible, use a “how much, by when” aim statement to guide your improvement work. If that level of specificity is not possible or appropriate, however, at least make sure your answer to “What are we trying to accomplish?” addresses the following issues:
- What system or process are you trying to improve? Indicate the setting of focus and/or population you plan to serve.
- What do you expect to happen? Specify your goal (and amount) of effort that points toward an outcome measure(s).
- What’s your time frame? It should create some urgency, and also prevent the work from becoming a never-ending improvement project.
- What other guidance for the team is useful to know? This might include specific changes to test, methods to use (co-design with patients), or limitations.
Finally, leadership support is essential. Leaders must help ensure an organization’s aims provoke new thinking and learning, and not fear and demoralization. If you are setting ambitious numerical goals for your improvement efforts, leaders must also support these efforts by allocating the staff time and resources necessary to achieve fundamental change.
In summary, an aim statement is an important component of an effective improvement journey. We hope these reflections are useful in you efforts to communicate the intent of your improvement efforts.
The authors thank Lloyd Provost from Associates in Process Improvement for his invaluable contributions to the development of this post.
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