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The QUERI Implementation Roadmap systematically guides identification, implementation, and sustainment of effective practices. The Roadmap demystifies implementation science for stakeholders in a Learning Health System to ensure that effective practices are more rapidly implemented into practice to improve overall consumer health.
David Goodrich, EdD; Isomi Miake-Lye, PhD; Nicholas Bowersox, PhD, ABPP; Veronica Williams, MPH; and Amy Kilbourne, PhD, MPH
Early in FY2019, HSR&D’s Quality Enhancement Research Initiative (QUERI) began deploying an updated Implementation Roadmap (“Roadmap”) to VA clinical operational partners and investigators to provide them with a comprehensive and pragmatic approach to help clinical stakeholders deploy evidence-based practices (EBPs) into routine care. EBPs are clinical innovations, interventions, technologies, or programs derived from randomized controlled trials that show positive impact on quality, timeliness, and efficiency of care for Veterans and their families. The intent of the Roadmap is to extend the current translational pipeline by providing a common guide based on state-of-the art implementation and quality improvement science for practitioners to follow when seeking to scale-up and sustain effective practices.
Since 1998, QUERI has provided an embedded research-operations model to reduce the long delay that typically occurs between the generation of research evidence and its application in routine clinical practice. QUERI also has led the development and application of implementation strategies, or theory-based methods designed to reduce barriers to EBP uptake into routine care. However, based on a review of current implementation and quality improvement frameworks by the Center for Evaluation and Implementation Resources (CEIR), a recent HSR&D Evidence Synthesis Program (ESP) review of implementation strategies used in real-world health systems to improve adoption of EBPs,1 and the experience of the 15 QUERI Programs,2 it was apparent that there were few models that provided health system stakeholders (clinicians, consumers, healthcare researchers, leaders, and mangers) with a clear pathway for rapid partnership with investigators to plan, deploy, and sustain EBPs.
Health systems like VA strive to continuously innovate and be responsive to changing system priorities, policies, and treatment practices. Thus, QUERI leadership saw the need to make the processes of implementation and quality improvement more user-friendly and accessible to frontline stakeholders tasked with delivering care and enacting changes in care delivery. The Roadmap was commissioned to extend the previous “pipeline” framework3 for implementation activities, which reflected a traditional, linear research process, to a model that is more agile, responsive, and iterative to match the needs of a dynamic healthcare environment. The Roadmap is consistent with HSR&D/QUERI rapid-cycle funding mechanisms that flexibly align research with health system priorities (i.e., opioid safety, suicide prevention), especially in support of implementing EBPs in VA facilities and Veteran Integrated Service Networks (VISNs) that lack implementation capability or resources.
The Roadmap extends the traditional translational research pipeline, incorporating recent advancements in quality improvement and implementation science, as well as key lessons from QUERI and other VA and health system leaders in implementing EBPs. Within the Roadmap, implementation is a dynamic process that requires active and engaged input from multi-level stakeholders who help identify, implement, and sustain EBPs over time. Effective uptake of EBPs is based on the use of implementation strategies that empower and motivate frontline stakeholders to sustain a new practice, while implementation is an iterative process that generates new questions and new knowledge based on rapid and systematic improvement cycles.
The Roadmap consists of three phases informed by the Learning Health System knowledge-to-action loop, as well as several other implementation theories and frameworks. See Figure 1.
Each phase of the Roadmap is detailed in Figure 2, with phases organized around three questions regarding activities necessary to:
- Support the uptake of the EBP,
- Activate stakeholders and delivery capability, and
- Optimize the use of data and measures to assess progress.
Each phase is linked by iterative, recursive cycles of experimentation and refinement consistent with rapid-cycle testing.
During Pre-Implementation, investigators and their operational partners work to identify a clinical priority need and goals (e.g., metrics for quality enhancement), relevant stakeholders, and an EBP (solution) to address this quality gap. Investigators are encouraged to conduct an evidence review of relevant clinical trials, including the clinical settings, when selecting an EBP (see VA Evidence Synthesis Program). Moreover, investigators and operational partners should agree on specific roles and responsibilities, evaluation questions and design, lines of communication, and products.
The Implementation Phase is characterized by the selection and deployment of an implementation plan that applies implementation strategies to enhance EBP uptake. Stakeholders identify implementation strategies that match barriers and facilitators identified during Pre-Implementation (i.e., EBP complexity, resources, organizational characteristics) to optimize practice uptake. Growing evidence suggests implementation strategies that combine the use of technical (transactional) and adaptive (transformational) leadership/management skills are most effective for addressing organizational barriers. Transactional, or “push” strategies (e.g., policies, tools to promote provider skill development in EBP use) develop delivery capacity by aligning EBP implementation with organizational performance metrics – and by adjusting implementation strategies to improve performance. Adaptive or transformational strategies promote “pull” factors, such as encouraging intrinsic motivation of frontline providers to adapt and use the EBP, enhancing provider ownership in the implementation process.
Examples of implementation interventions that have used transformational strategies include Implementation Facilitation, Learning Healthcare Improvement, and Evidence-based quality Improvement, detailed in the article below on the new QUERI Implementation Strategy Training Hub sites.
The Sustainability Phase includes continuous monitoring of EBP fidelity, quality, outcomes, system impacts, and longitudinal return-on-investment (i.e., how much it will cost to maintain implementation over time per site) of the EBP. The goal of this phase is for the EBP to be maintained internally without the need for external support or management. For the EBP to be sustained, leaders should be provided with guidance on how to encourage sustainability, including program monitoring and resourcing—independent of outside support. This phase also involves identification of an EBP maintenance “owner” once external funding for implementation ends.
The Roadmap Going Forward
The QUERI Implementation Roadmap4 was designed to provide a pragmatic framework with which to align QUERI’s strengths as an embedded research service to meet national health system priorities. It provides a comprehensive and user-friendly approach via implementation strategies to deploy EBPs, while using strong program evaluation methods to monitor impact. Additionally, the Roadmap plays an integral role in the new Office of Research and Development (ORD) Research Lifecycle5 that calls for a coherent approach to accelerate the translation of clinical research into real world practice. The Roadmap is doing this in VA via multiple channels, by:
- Enabling the VA Cooperative Studies Program (CSP) to have a framework to help investigators incorporate implementation science methods in clinical efficacy and effectiveness studies;
- Serving as a common guide for VA facilities to support the scale-up and spread of promising EBPs in VA’s Diffusion of Innovations Ecosystem; and
- Providing a common framework for QUERI’s Implementation Science Training Hubs to train VA practitioners, researchers, and clinical operational leaders in the basic elements of implementation science, quality improvement, and program evaluation.
For more information about applying the QUERI Implementation Roadmap and additional resources, contact the CEIR Program Manager, Veronica Williams, at Veronica.Williams9@va.gov .
- Miake-Lye I, Mak S, Lambert-Kerzner A, at el. Scaling beyond early adopters: A systematic review and key informant perspectives. VA ESP Project #05-226; 2019.
- Atkins D, Kilbourne A, and Shulkin D. Moving from discovery to system-wide change: The role of research in a learning health care system: Experience from three decades of health systems research in the Veterans Health Administration. Annual Review of Public Health. March 2017;38:467-487.
- Stetler C, McQueen L, Demakis J, et al. An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series. Implementation Science. May 2008;3.
- Kilbourne A, Goodrich D, Isomi Miake-Lye I, et al. Quality Enhancement Research Initiative (QUERI) Implementation Roadmap: Toward sustainability of evidence-based practices in a learning health system. Medical Care (In press, October 2019).
- Kilbourne A, Braganza M, Bowersox N, et al. Research lifecycle to increase the substantial real-world impact of research: Accelerating innovations to application. Medical Care (In press, October 2019).