Ready or Not? Exploring the Equity Implications of Readiness
By Dr. Sobia Khan, Director of Implementation
4-min read
Readiness has been at the top of many people's minds in terms of implementation, spread, and scale. In fact, readiness is one of the most prominent topics people have questions about in our Implementing Change Community open support sessions, workshops, and collaborative projects. It is easy to imagine why this is a challenge. Implementing changes and supporting different teams to move forward is often difficult. One of the common barriers people face is the knowledge that teams may not be willing or able to make progress for many different reasons.
Setting the groundwork for readiness assessment
We started diving deep into readiness when we were supporting implementation research projects many years ago and realized that we had to get a good sense of site readiness to determine how different sites would be supported.
First, we had to get a handle on what it means to be “ready.” We learned that readiness is both structural and psychological – this means that the implementation setting must be structurally prepared to implement (e.g., have the right resources, policies, equipment, etc.) and that people in the implementation setting also have to collectively demonstrate psychological markers of readiness, like collective commitment, a feeling that things need to change, and making this change a priority.
Second, we had to think about what assessment tools adequately capture these readiness constructs – which led us to develop the Ready ,Set, Change! Decision support tool for people who want support selecting the right tool for their initiatives (see these articles for more info on how we developed and tested the tool). We realized through this work almost 10 years ago that there was a need to better assess and address readiness.
We have assessed readiness: Now what?
One of the biggest issues we recognized back then and still grapple with today is what to do with a readiness assessment. When we first started learning about readiness, we asked implementation researchers what to do with the results of the readiness assessments. They suggested using readiness assessments as a way to select sites. However, there was, and still is, no “benchmark” for readiness to tell you whether or not a setting is ready. Plus, we were not in a position to select sites – all of the sites that completed the readiness assessment were going to implement. There was, and still is, relatively little guidance on how to support teams that are not ready.
We wanted to understand how to interpret and use the readiness assessments. For example, for sites scoring similarly overall, but with different strengths and challenges, were they really the same? For sites receiving a low score, what if they possessed certain “heavily weighted” or “make or break” readiness characteristics that meant they actually had a chance of success even with a low score? We even encountered a site once with the highest readiness score across the board, except for one domain – tension for change. Ultimately, that site did very poorly in implementation. This led us to wonder which aspects of readiness might be more important than others.
We just didn’t know about the nuance of readiness assessments other than using an assessment and determining a score. Researchers recommended prioritizing sites that were considered "more ready," but this approach seemed arbitrary and unfair. What if certain settings are repeatedly deemed unready and never receive research support or funding opportunities? Therefore, we must consider the equity implications of readiness assessments and think more critically about them.
Equity and readiness
One of the biggest light bulb moments we have had in recent years was related to the equity implications of readiness assessments. In talking with others in the implementation research and practice space, this is definitely an area that others want to continue delving into.
The problem with the “ready or not” mentality is that to boost our chances of success, it is easy to select sites that are more ready and leave other sites behind. The ones that get left behind often need more support (and may need the program or practice more than the ready sites).
Instead of a ready or not mentality, we like to talk to people about the process of meeting people where they are at – i.e., that a readiness assessment can (and should) be used to determine where sites are currently at in terms of levels and readiness and that a key part of an equitable implementation process is to engage in readiness building.
In fact, we at TCI think that readiness building is a new frontier for implementation science and that it has amazing implications for research and practice. It helps to have a mindset that we can and should do the messy and hard work of readiness building as part of sustainable implementation and to ensure that all settings have a shot at implementing changes that will meet their needs.
If implementation researchers selected sites that are less ready, we could learn much more about what is required to support these sites. Supporting less-ready sites is one way that implementation practitioners can implement more equitably.
The concept of readiness is at a pivotal point in the ever-evolving landscape of implementation. By considering readiness, we can shape the trajectory of change initiatives. Our journey in understanding readiness has involved many twists and turns. Our approach has shifted from a binary "ready or not" mindset to meeting individuals and settings where they are, fostering a culture of readiness building that transcends an assessment score. As we chart this new frontier in implementation science, we're excited to learn more about what the field can unearth about how to support sites without excluding sites based on their level of readiness.
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