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Successful implementation of healthcare programs or policies is complex, often messy, and hard to sustain. Moreover, investigators are not often incentivized to further sustain implementation efforts once launched, in part because the academic career track rewards innovation through new papers and grants rather than direct quality improvement or impacts on patient populations or programs and policies. In addition, the needs of the operations partner are not always aligned with the scientific interests of the investigator.
In its 2015 reorganization, QUERI sought to incentivize implementation practice rather than research, and better align investigator interests with implementation priorities that better addressed the problems directly facing VHA operations leaders. Through its trifecta of priority goals—more rapid implementation, rigorous evaluation, and promoting implementation science—QUERI is leading the way in what is being called “embedded” research, in which scientific expertise is used to solve high-priority problems directly identified by health systems though a deliberate process of innovation, investigation, and implementation/sustainability.
As described below, QUERI investigators partner with multiple VHA national program offices and operations leaders in various capacities, which can be broadly categorized by the following descriptions:
- Coalition-building across health system partners: The National Network of QUERI programs are required to involve at least two distinct national program office partners, which ensures that the effective practices to be implemented have strong support across different clinical function and specialty areas. Programs such as the Women’s Health QUERI (EMPOWER QUERI) work with the Women’s Health national program office and Primary Care to improve quality of care for women Veterans. The Programs also provide more stability than the grant cycle process by promoting capacity-building in implementation and evaluation methods.
- Problem-focused implementation: The QUERI-VISN Partnered Implementation Initiatives described below involve the VA regional network (VISN) leaders in the selection of clinical priorities via a field-based nomination process and live voting at the National Leadership Council meetings. Applications must be co-led by a VISN leader and an implementation expert and must aim to improve quality based on VHA national performance standards.
- Problem-focused evaluation: The 20+ QUERI partnered evaluation initiatives are co-funded by VHA program offices to conduct evaluations directed by the operations partner. QUERI Partnered Evaluation Initiatives such as the Complementary and Integrative Health (CIHEC), Office of Health Equity-QUERI, and PACT Intensive Outpatient Management centers described below have rapidly expanded in order to meet the growing need among VHA operations leaders for rigorous evaluation and implementation support, many of which have been sustained over time due to deepening partnerships between the investigators and VHA program offices.
- Partnered consultation: QUERI’s Resource Centers, notably the Center for Evaluation and Implementation Resources (CEIR) and the Partnered Evidence-based Policy Resource Center (PEPReC) were funded to meet evaluation and implementation capacity needs across the VA healthcare system. For example, PEPReC is currently conducting national policy analyses to estimate demand for services and model different access to care strategies. CEIR regularly consults with regional and national program office leaders to identify QUERI centers that could support further implementation and evaluation work. More recently, CEIR has coordinated learning opportunities for frontline providers in implementation practice (e.g., evidence-based quality improvement) in order to demystify implementation science and widen the tent of providers working in this area.
QUERI continues to grow its capacity for embedded science, notably by taking on the challenge of ensuring that national clinical priorities work at the clinic (frontline provider) levels. QUERI investigators work in tandem with local and national health system leaders to identify clinical priorities and interventions, support implementation of effective practices, evaluate quality improvement, and ensure a sustainability plan that is embedded within the health system.
More health system leaders within and external to VA seek expertise from QUERI centers to help implement effective practices that address challenging healthcare issues. To this end, QUERI seeks to disrupt the academically-driven investigator career cycle to further incentivize and support problem-focused implementation, where the primary outcomes include quality enhancement and patient impacts, and investigators are rewarded on sustainability of effective practices over time.
Amy Kilbourne, PhD, MPH
Director, Quality Enhancement Research Initiative