Model for Improvement question: What are we trying to accomplish?

The three fundamental questions in the Model for improvement can be addressed in any order, although teams typically start with the first question — What are we trying to accomplish? — to guide them in setting aims.

Answering the model’s three questions is an iterative process — the team moves back and forth between them as changes in thinking in one question or learning from PDSA cycles results in changes in thinking in another.

Setting an initial aim is essential to starting an improvement initiative. An organization will not improve without a clear and firm intention to do so.

Elements of an effective aim: 

• What we are improving
• By what date and how much we want to improve: Time-bound and measurable (how much? by when?)
• For/with whom are we doing this work: Define the specific population whose lives will be affected by the improvement effort
• Where the improvement is taking place

Agreeing on the aim is crucial, as is allocating the people and resources necessary to accomplish the aim. Engage the individuals who will most benefit from the improvement on the improvement team and in defining the aim.

To help develop improvement project aims, health care organizations often use the six overarching "Aims for Improvement" outlined in the 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century:

• Safe: Avoid injuries to patients from the care that is intended to help them.
• Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care.
• Patient-Centered: Honor the individual and respect choice.
• Timely: Reduce waiting for both patients and those who give care.
• Efficient: Reduce waste.
• Equitable: Close racial and ethnic gaps in health status.

Tips for Setting Aims

Co-Design the Aim

Ensure that individuals who will most benefit from the improvement are members of the team that is defining the aim(s). “Customers” of the process, individuals with lived/living experience, and stakeholders in the community that receive care all have insights into the experience of care, what is likely to be successful, and know how to engage people in change that the health system cannot access alone.

Choose Aims That Explicitly Close Equity Gaps

Look at why one group of individuals may be experiencing different outcomes than other groups. Explicitly call out systemic barriers like racism, ageism, primary language, and other factors that have led to the inequitable outcomes that you seek to address with the improvement project. Remember that improving for all may lead to equality but not to equity, while improving for those with the worst outcomes will benefit everyone.

State the Aim Clearly

Teams make better progress when their aims are specific, clear, and simple. The essential elements of an aim statement include:

• What we are improving
• By what date we want to see improvement, ideally expressed as month and year (e.g.,“by October 2028”) rather than as a general timeframe (e.g., “within 10 months”)
• How much we want to improve (what success would look like), stated in numerical goals
• For/with whom are we doing this work
• Where we are doing the work
• Sometimes explaining why is also helpful

Include Numerical Goals When Possible

Teams are more successful when they have unambiguous, focused aims, ideally with numeric goals that clearly signal what success would look like. This helps to create a burning platform for change from the current performance to improved performance.

For example, the aim "Reduce preterm births among Black birthing people" is not as effective as "Reduce preterm births among Black birthing people from 15% to 9% by August 2025." The numerical goals also help team members begin to think about what their measures of improvement will be, what changes they might test, and what level of support they will need.

However, numerical goals must be established rationally — there should be a clear line of site between the theory of what changes are likely to result in improvement, the resources allocated, the measurement system, and the numerical goals stated in the aim.

Set Stretch Goals

A "stretch" goal is one to reach for within a certain time. Setting stretch goals in an aim statement — such as "Reduce preterm births among Black birthing people from 15% to 9% by August 2025" — communicate immediately and clearly that maintaining the status quo is not an option.

Effective leaders make it clear that the goal cannot be met by simply tweaking the existing system. Once this is clear, people begin to look for ways to fundamentally redesign the current system and overcome current barriers to achieve the stretch goals. Be sure to align stretch goals with the system identified, the scope of the change ideas, and the resources available to the team.

Be Careful of Aim Drift

Once the aim has been set, the team needs to be careful not to back away from it deliberately or "drift" away from it unconsciously. The initial stretch goal "Reduce preterm births among Black birthing people from 15% to 9% by August 2025" can drift to become "Reduce preterm births among Black birthing people to 12%” — or the focus can shift to something different and less explicit, such as “Improve the experience of Black birthing people.” Revising the initial aim isn’t necessarily a bad thing, as long as the change is acknowledged explicitly by the team and relevant stakeholders and the revised aim includes best-practice elements.

To avoid drifting away from the aim, repeat the aim continually. Start each team meeting with an explicit statement of aim — "Remember, we’re focusing on reducing preterm births among Black birthing people from 15% to 9% by August 2025" — and then review progress quantitatively over time.   

Be Prepared to Refocus the Aim

Every team needs to recognize when to refocus its aim. If the team’s overall aim is at a system level (e.g., "Increase access to cancer care for Latinx patients by reducing waiting time for appointments from 4 weeks to 2 weeks by January 2026"), team members may find that focusing for a time on a smaller part of the system (e.g., "Increase access to breast cancer screening for Latinx patients by 30% by May 2025") will help them achieve the desired system-level goal.

Note: Don’t confuse aim drift or backing away from a stretch goal (which usually isn’t a good tactic) with consciously deciding to work on a smaller part of the system (which often is a good tactic).

Examples of Effective Aim Statements

• Improve the patient experience during delivery for Black birthing persons as measured by an increase in patients reporting they were listened to from 25% to 75% by June 2024
• Increase colon cancer screening rates among patients ages 50+ who identify as Chinese from 50% to 70% by May 2025
• Reduce harm from use of anticoagulants from the current rate of 1.8 per thousand admissions to less than 1.4 by January 2025 and less than 1 per thousand admissions by January 2026
• Reduce waiting time to see a physician for all patients ages 65+ who identify as Black, Indigenous, or people of color to less than 15 minutes by July 2024
• Increase the percentage of patients whose primary language is not English that are transferred from the emergency department to an inpatient bed within 1 hour of the decision to admit from 25% to 50% by March 2024
• Increase the percentage of patients ages 50+ who self-identify as Black, Indigenous, or people of color that are transferred from the inpatient facility to a long-term care facility within 24 hours, after the patient is deemed ready to transfer, from 58% to 75% by April 2026
• Reduce average ventilator days by 2 to 4 days per discharge by November 2024
• Reduce adverse drug events (ADEs) per ICU day by 75% (or absolute number of less than 0.10 ADEs per ICU day) by December 2026