QUERI – Quality Enhancement Research Initiative

Go to the HSRD website

FLOW3: Diffusion of Excellence Gold Status Practice – Enterprise-Wide Diffusion

Seattle, WA and Denver, CO


FLOW3 is a novel workflow computerized management system that incorporates three custom-designed applications to facilitate the process for obtaining prosthetic limbs for Veterans.

The Veterans Healthcare Administration (VHA) provides care for more than 50,000 Veterans with major limb loss, including those with amputations secondary to combat. Across VHA, the prosthetic limb care process is labor and time intensive, inconsistent across facilities, and difficult to coordinate between front line staff (e.g., clinical, administrative, logistics and acquisition). To address these challenges, investigators with the FLOW3: Diffusion of Excellence Gold Status Practice – Enterprise-Wide Diffusion QUERI Partnered Evaluation Initiative have developed a computerized management system to optimize the prosthetic limb process by improving the:

  • Timeliness in providing prosthetic limbs to Veterans,
  • Data systems that manage and report on prosthetic limb provision,
  • Employee satisfaction, and
  • Veteran customer experience.

FLOW3 is comprised of three inter-related computerized applications (prosthetic limb consult template, consult comment tool, and web-based app) that support prosthetic care from prescription, specification, procurement, fabrication, delivery, and verification. The FLOW3 system makes the prosthetic limb process more predictable and consistent, creating a high-quality experience for Veterans and staff. As a result, FLOW3 was identified by QUERI, Rehabilitation and Prosthetics Services (RPS) and Diffusion of Excellence (DoE) as one of the practices that will be supported to facilitate further implementation and expansion to other Veterans Integrated Service Networks (VISNs) and at Regional Amputation Centers of VHA’s Amputation System of Care (ASoC). The ASoC provides specialized expertise in amputation rehabilitation, incorporating the latest practices in medical rehabilitation management, rehabilitation therapies, and advances in prosthetic technology.

The DoE initiative helps identify and disseminate clinical and administrative best practices, empowering top performers to apply their innovative ideas throughout VHA.


Using a mixed-methods formative and summative evaluation of FLOW3 implementation, QUERI investigators will:

  • Evaluate the perspective of providers, based on provider satisfaction with the FLOW3 system and with training materials and implementation of FLOW3.
  • Assess the impact of FLOW3 on Veterans’ experience with the process of receiving a prosthesis – and the most appropriate prosthesis to achieve the Veteran’s functional goals.
  • Identify system-level impact of FLOW3 on the timeliness of the provision of prosthetic limbs to Veterans, efficiency of the process of ordering a prosthetic limb, cost of the provision of prosthetic limbs, and return on investment of implementing the FLOW3 process.
  • Develop an interactive, web-based implementation toolkit to facilitate the national expansion of FLOW3 based on an evaluation of barriers and facilitators to implementation at VISN 22 facilities and Regional Amputation Centers.

Potential Impacts:

FLOW3 addresses challenges related to the complex process and high costs of prosthetics. This evaluation will expand our understanding of FLOW3 impacts, particularly the effects of FLOW3 on Veterans’ experience. It also will assess system-level changes in timeliness, cost, and return on investment. Moreover, the assessment at FLOW3 expansion sites will help establish best practices for FLOW3 implementation – and will inform the development of an implementation toolkit.

Co-Principal Investigators: Michael Ho, MD, MPH; Co-Director of HSR&D’s Seattle-Denver Center of Innovation; Jeffrey Heckman, DO, Regional Amputation Center – Seattle, VA Puget Sound Health Care System; and Chelsea Leonard, PhD, investigator with HSR&D’s Seattle-Denver Center of Innovation.

Operational Partners: VISN 22, VA Desert Pacific Healthcare Network.  VISN 9, VA MidSouth Healthcare Network.