3 Appendix C

Appendix C – Organizational Readiness for Implementation Change (ORIC)

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

Organizational Readiness for Implementation Change (ORIC) – Practice Leader/Administrator/Practice Champion

MedStar Health Research Institute (MHRI) will conduct an interview with up to twenty (n=20) practice champion/administrator/provider to assess practice readiness to change. The information is collected at the practice level, not the individual level.

Recruitment Criteria

Any practice champion/administrator/provider that has practice level line of sight on organizational and operational priorities may complete the practice-level survey.

Location and Schedule

The change readiness survey will be completed online. The survey will take approximately 12 minutes to complete.

Informed Consent Procedures

Informed consent will be completed online with a survey cover page.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

Organizational Readiness for Implementing Change (ORIC)

	1	2	3	4		5
	Disagree	Somewhat Disagree	Neither Agree nor Disagree	Somewhat Agree		Agree
People who work here feel confident that the organization can get people invested in implementing this change.					1 2 3 4 5
People who work here are committed to implementing this change.					1 2 3 4 5
People who work here feel confident that they can keep track of progress in implementing this change.					1 2 3 4 5
People who work here will do whatever it takes to implement this change.					1 2 3 4 5
People who work here feel confident that the organization can support people as they adjust to this change.					1 2 3 4 5
People who work here want to implement this change.					1 2 3 4 5
People who work here feel confident that they can keep the momentum going in implementing this change.					1 2 3 4 5
People who work here feel confident that they can handle the challenges that might arise in implementing this change.					1 2 3 4 5
People who work here are determined to implement this change.					1 2 3 4 5
People who work here feel confident that they can coordinate tasks so that implementation goes smoothly.					1 2 3 4 5
People who work here are motivated to implement this change.					1 2 3 4 5
People who work here feel confident that they can manage the politics of implementing this change.					1 2 3 4 5