QUERI – Quality Enhancement Research Initiative

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Diffusion of Excellence and QUERI: Making a Difference

Recently, VA’s Diffusion of Excellence initiative called on QUERI to help support the uptake of best practices. The Initiative was established in 2015 by then VA Undersecretary of Health David Shulkin, MD (currently Secretary of VA) to promote innovation and diffusion of best practices, based on the recommendations from the external evaluation of VA care under the Veterans Choice Act. Specifically, the evaluation concluded that “A systematic effort is needed to identify unwarranted variation, identify and develop best practices to improve performance, and embed these practices into routine use across the VA system.” However, the widespread adoption of best practices has been challenging health systems, and evidence-based clinical practices can sometimes take more than a decade to reach patients consistently. Faced with this challenge, how does VA implement and spread an innovation that proves to be a best practice in a VA medical center in Maine, for example, to other VA facilities across the country?

The Diffusion of Excellence initiative identifies promising practices by soliciting them directly from frontline VA employees, using a web-based knowledge hub and operational platform (VA Diffusion Hub) that receives approximately 600 submissions from employees per year. Frontline employees from selected practices have an opportunity to “pitch” their innovative best practice to VA leadership in a virtual “Shark Tank” where VISN (Veterans Integrated Service Networks) and medical center directors bid on these practices, pledging additional support to facilitate implementation. On average, 10 practices receive the designation of “Gold Status” and undergo a six-month facilitated “replication” at multiple VA sites. During this implementation period, investigators work closely with frontline VA employees who deal with the daily challenges inherent in the nation’s largest integrated healthcare network. Investigators take their input and feedback – particularly about barriers to change – and use that information to help spread innovations that work in “real world” settings across the VA healthcare system.

VA recently completed its third Shark Tank and, as a result, there are 10 Gold Status Practices being replicated across the country at more than 30 sites, targeting issues that include suicide prevention, opioid safety, and new models of care.

Ryan Vega, MD, MSHA is the Diffusion of Excellence Lead with the VA Center for Innovation as well as a practicing hospitalist at the Hunter Holmes McGuire VA Medical Center.

Below Dr. Vega answers a few questions about this exciting initiative.

VA just conducted its third Shark Tank and 10 Gold Status Practices are undergoing facilitated implementation. Can you tell us how this round differed from the first two?

RV: The Diffusion of Excellence initiative was started in September of 2015. Given its short lifespan, it is really amazing to see the level of engagement of frontline VA healthcare providers, as well the quality of submissions that have come into the Shark Tank. One of the key differences we noticed about the current cohort of Gold Status Practices, as compared to the last, is the number of facilities at which these practices had already been replicated. Several had already spread across their VISN, and I think this a testament to the frontline dedication to fostering a commitment to excellence and creating a learning health system. Another difference is the array of practices – we are seeing both promising administrative and clinical practices tackling challenges from all angles, be it new processes or digital solutions.

What is your best advice for researchers who want to pitch in the next round of Shark Tank?

RV: Be bold! I believe VA has the greatest employees, and we are discovering their amazing ideas and practices every day. However, going into the Shark Tank is not easy. I think a lot of individuals are hesitant to sell their product, so to speak. This is an amazing opportunity for all employees to showcase their work, receive valuable feedback, and possibly even get selected.

In what ways is the Diffusion of Excellence initiative working with QUERI to promote best practices?

RV: We are working with QUERI on several fronts, but perhaps the most important is the qualitative analysis of what is driving adoption and spread on the frontline. Diffusion of Innovation is a challenging concept, it doesn’t just happen. There is a science to implementation and particularly in healthcare, there is incredible opportunity for us to learn more about spread of best practices and what models can facilitate adoption in a timely manner. Thus far, the lessons QUERI has learned have been invaluable in informing the future strategy, growth, and operational models for the Diffusion initiative.

What are some specific advantages for researchers who work with frontline providers in implementing best practices?

RV: No one has a better vantage point than those on the frontline. This is especially true when considering the adoption and spread of best practices across a healthcare system. Those on the frontline are not just adopting a practice; they must implement, execute and inevitably deal with the results, whether positive or negative. There is so much we often miss at the macro-level when considering the diffusion of innovation, and working with frontline providers offers access to those “doing the work.” This allows researchers to truly develop an understanding of what affects implementation, not just the perception of what impacts implementation.

Dr. Shulkin is an enthusiastic supporter of the Diffusion of Excellence initiative. How has his support made a difference?

RV: Leadership support in any organization is vital, but that support is not always visible to the organization. Dr. Shulkin’ s support for Diffusion is clearly visible, and I believe his enthusiasm extends beyond support – I think he is truly committed to transforming the VA and Diffusion is one example of that commitment. Our Gold Status and Implementing Fellows comment frequently that they “feel connected to VA for the first time in a while.” I think this is a direct result of that visible support. Without the vision and hard work of Shereef Elnahal, MD, MBA, VHA Assistant Deputy Under Secretary for Health for Quality, Safety & Value, and Carolyn Clancy, MD, VHA Executive in Charge, at the onset of this initiative, coupled with the ongoing support by Dr. Shulkin, Diffusion of Excellence would not be where it is today.

For more information, you may watch a video featuring Dr. Vega and Diffusion of Excellence Gold Status Fellow, Dr. Ellina Seckel. You also may reach Dr. Vega at Ryan.Vega@va.gov .

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