QUERI – Quality Enhancement Research Initiative

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Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK)

Durham, NC, Ann Arbor, MI, and Bedford, MA


In October 2015, the Under Secretary for Health initiated the VA Diffusion of Excellence Initiative (DEI), which identifies the best projects and prototypes that can be replicated to improve the quality of VA healthcare. The DEI aims to empower VA employees to develop promising practices in care and administrative processes, institutionalize the processes for implementing and spreading promising practices, and minimize negative variation in these practices across the VA healthcare system.

The Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) Partnered Evaluation Initiative is designed to provide rapid and frequent feedback to DEI partners by:

  • Addressing factors aimed at increasing participation in the DEI;
  • Helping increase organizational readiness for change within VA facilities to successfully implement "gold status best practices;" and
  • Addressing key contextual factors that are associated with successful implementation of gold status practices at medical facilities across the VA.


To evaluate the impact of the Diffusion of Excellence by addressing the following aims:

  • Identify factors associated with participation in the DEI.
  • Examine VA leaders' (i.e., medical and VISN directors) decision-making processes when choosing to bid resources for implementation of gold status practices and relate processes to perceived organizational readiness for change.
  • Conduct process evaluations to understand influences on implementation success within implementing facilities and grassroots facilities.
  • Use Qualitative Comparative Analysis to identify pathways toward broader diffusion and successful implementation of gold status practices.

An anticipated evaluation outcome is the increased ability of DEI partners to provide effective "personalized implementation" (organizational-level and person-level human centered design) of promising practices.


This evaluation will rely on quantitative, qualitative, and mixed-methods to evaluate the DEI, primarily through using the Consolidated Framework for Implementation Research (CFIR) in combination with the Theory for Organizational Readiness for Change to explain adoption decisions and subsequent implementation experiences. Investigators will conduct analyses using three primary data sources: 1) Promising Practices Diffusion Hub, 2) VA All Employee Survey (AES), and 3) facility-level characteristics available through the VA Support Service Center (VSSC) to identify organizational factors associated with VA facilities that propose gold status practices. Through a series of qualitative interviews with VA leaders, Gold Status Fellows, and Implementing Facility Fellows, the team will assess organizational and leadership factors associated with choosing or not choosing to participate and implement gold status practices within facilities.

The Shark Tank process - proposed by Under Secretary of Veterans Affairs, Dr. David Shulkin - works to identify solutions developed by employees that can then be shared across the VA healthcare system to directly improve patient experiences. As part of the process that involves implementing gold status practices, investigators will assess the decision-making process that VA leaders use when bidding resources for implementation, as related to perceived organizational readiness for change. Finally, investigators will utilize the Qualitative Comparative Analysis to examine potential combinations of necessary and sufficient factors associated with the implementation success of gold status practices

Operations Partners

The key partners for this evaluation are the Office of Strategic Integration (OSI), which works with stakeholders to improve organizational efficiency and the successful implementation of health and business programs, and Office of the Assistant Deputy Under Secretary for Health for Quality, Safety and Value in cooperation with the VA Center for Innovation (VACI).

Principal Investigators: George L. Jackson, Ph.D., MHA (corresponding PI, Durham, NC), contact at George.Jackson3@va.gov; Laura Damschroder, MS, MPH (Ann Arbor, MI), contact at Laura.Damschroder@va.gov; and Thomas K, Houston, MD, MPH (Bedford, MA), contact at Thomas.Houston2@va.gov .