Expanding and Enhancing Implementation Learning
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Nick Bowersox, PhD, ABPP
Led by Nick Bowersox, PhD, ABPP, QUERI’s Center for Evaluation and Implementation Resources (CEIR) provides time-sensitive consultation and support to help VA policymakers, managers, providers, and researchers scale-up and spread promising innovations and effective policies, programs, and practices. In addition to directing CEIR, Dr. Bowersox is an investigator with VA’s Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC). His work focuses on the evaluation of healthcare quality, treatment disparities for patients with serious mental illness (SMI) – and examining the intersection of recovery and integrated care for patients with SMI within the VA healthcare system.
In a recent interview with CIDER’s QUERI Dissemination Coordinator, Diane Hanks, MA, Dr. Bowersox spoke about what CEIR offers not just to HSR&D but to all of VA, and why it’s important in our efforts to improve the health and care of Veterans.
When and why was CEIR created? And who can use CEIR as a resource?
CEIR was launched in 2017 with the goal of being the centralized resource in VA for best practice guidance related to implementation science and program evaluation. We view our “customer base” as all of VA, in that we think implementation science and program evaluation really touch aspects of the work that everyone in VA does to one extent or another. We work to develop resources, mentor/learning opportunities, and guide materials so that VA stakeholders can understand best practices in these areas and really appreciate how they’re relevant to their work on many different levels. In fact, the Evidence Act [Foundations for Evidence-Based Policymaking Act] suggests that everyone should have a formal evaluation of clinical programs and policies, and the Learning Healthcare System model points to the need to rapidly translate research to practice and vice versa.
The Evidence Act, which became a public law in January 2019, requires agencies to submit annually to the Office of Management and Budget and Congress a systematic plan for identifying and addressing policy questions. This includes methods and analytical approaches that may be used to develop evidence to support policymaking.
We want to make our resources available to everyone who needs them and meet people at different levels in terms of their learning goals – from those who only require a basic introduction in order to understand why they should care about implementation science to non-researchers who run programs or manage operational offices and want to understand what implementation science is and how to apply it to the work they do (implementation practitioners). A great resource for implementation practitioners are QUERI’s seven Implementation Learning Hubs located around the country (noted above), where implementation science experts have developed structured curricula and strategies that enable people to use these tools in an applied way. CEIR serves as a coordinator – connecting investigators and clinical managers to the Learning Hub that will best fit their needs. The Learning Hubs are also ideal for HSR&D researchers and career development awardees who want to apply implementation science to their research. We’ll connect people at this level to the QUERI implementation mentoring cores, where established implementation scientists will mentor junior investigators and provide hands-on experience.
CEIR supports these activities by making connections across various QUERI centers, programs, and learning hubs. We’ve also developed self-educational tools such as the QUERI Implementation Roadmap, which is a quality improvement guide that provides a framework for designing and carrying out a quality improvement project [read more about this resource below]. CEIR has also created an Implementation Science, Knowledge Translation, and Quality Improvement Resource Matrix that organizes several valuable resources based on the level of expertise people want to achieve – and what level of guidance they prefer.
All Diffusion Academy and Gold Status Practice Teams have access to CEIR resources. Can you describe how CEIR helps these investigators with potential partnerships and training opportunities to facilitate implementation?
Diffusion of Excellence has been a very interesting partner for us. We work with them on their annual training and in reviewing some of their initial submissions for potential practices. It’s really an exciting opportunity for us to collaborate with frontline staff who have an innovative practice that they think can spread to other VA sites. Some people who participate in the Diffusion Academy are very dynamic and effective at changing practice at their own site and maybe one other, but they run into challenges in trying to spread it past that point. We work with clinicians and/or researchers so that they can build teams to help them spread their practices, often by focusing on measurement of clinical impact and developing clear spread plans, and these things can mean the difference between spreading a new practice between 2 sites or to 20 or more sites.
VA’s Diffusion of Excellence scales emergent, high-impact healthcare practices across the VA healthcare system. VA’s Diffusion Academy takes mature innovations that are ready to take the next step and helps researchers build the groundwork for sustaining and scaling their practices.
Please discuss CEIR’s work with VA’s Cooperative Studies Program (CSP), which conducts multi-site clinical trials, regarding implementation.
VA’s Office of Research & Development (ORD) decided that large-scale clinical trials in VA should have considerations related to intervention implementation built in from the beginning. In the past, VA has conducted important clinical studies with great demonstrations of potential clinical impact, but there was limited uptake of the interventions into daily clinical practice. A discussion related to this situation was started with CSP, which runs VA’s large-scale clinical trials, on what could be done to get interventions adopted by frontline providers in the aftermath of trials that show that new interventions are more effective than treatment as usual. This led to discussions with QUERI, and then with CEIR.
We’ve been working with CSP leadership for more than a year on the best ways to build implementation science (IS) into large-scale clinical trials. During these discussions, we’ve found that we need to focus on several different areas: How to bring in IS expertise (i.e., we recruited QUERI implementation experts to work with trial teams); Developing standard expectations for implementation as an element of a trial (i.e., by establishing hybrid 1 trials that focus on untested interventions); and Using the QUERI Implementation Roadmap to provide structure. We’ve also been working with CSP to develop internal capacity so that they can include implementation in their trials without QUERI’s ongoing help. In that respect, CEIR is developing internal training materials so that everyone involved in CSP trials can learn more about implementation science.
CEIR recently developed the Implementation Roadmap, with contributions from more than 50 multi-disciplinary experts and health system leaders. How might this Guide help VA investigators?
The Implementation Roadmap is a quality improvement framework guide that walks readers through the steps of designing and carrying out a quality improvement project, including best practice recommendations for program evaluation and implementation science.
The roadmap focuses on three crucial periods: pre-implementation planning, implementation of the program, and sustainment once initial implementation efforts wane. Readers are also guided through the process of selecting a particular intervention that best fits the needs of the area of concern, considerations to help measure the impact of the intervention, and steps to identify key stakeholders who will support implementation efforts. In addition, the Guide contains a list of relevant resources to support further education related to applied implementation science, as well as some examples of VA programs that were supported through approaches such as those in the Guide.
The Implementation Roadmap Guide can serve as a stand-alone reference for self-education – or it can provide the foundation for the development of projects which can then be brought to VA implementation experts for consultation and refinement. The Guide is consistent with other training opportunities available in QUERI, such as the QUERI Implementation Learning Hubs. Finally, the Guide is included in guidance for investigators interested in applying for QUERI funding as a strong recommendation to improve consistency in implementation projects across VA, so awareness of the Guide will lead to more informed applications for QUERI funds.
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