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The U.S. healthcare system is changing, and health services researchers must respond to the changing needs of VA – one of the largest single providers of healthcare in the U.S., as well as the changing needs of Veterans. During a recent meeting held at the National Academy of Medicine, it was strongly suggested that health services researchers conduct more problem-focused research, that is, become embedded in the healthcare system and address the nuanced issues that have a high impact on clinical care, especially when new technologies or policies are introduced. However, the Academy also acknowledged that health services researchers are not currently rewarded to work on these types of health system problems, especially when the incentives are aligned to generate more papers and more research funding rather than showing a real impact on patient health.
QUERI has sought to realign these investigator incentives, notably through the funding of more rapid implementation projects, national policy evaluations, and implementation capacity building. Recently, QUERI changed the way it funded its Programs (Centers), lengthening the funding duration to encourage investigators to work more closely with local site leadership and national operations to implement effective practices. Most recently, QUERI was added to the VHA Facility and Network Director Performance Plan, where leaders receive a larger bonus if they demonstrate that they are implementing effective practices derived from QUERI-funded investigations across several sites. QUERI Programs also had to work on common healthcare priorities that cross more than one condition or program office so that their work was more sustainable, and they built a coalition across organizational units.
In the latest RFA (Request for Application), QUERI seeks to further increase the impact of health services and implementation research through three mechanisms. First, investigators who apply for the VISN Partnered Implementation Initiative are funded to work directly with VA integrated service network leaders to make real changes to the quality of care for VA top clinical priorities. Applicants receive more funding if they can show real change in quality of care indicators for these conditions. Further, the QUERI partnered evaluation mechanism, which requires co-funding from operations leaders, enables QUERI investigators to jumpstart evaluation centers for VISN or national program offices, who can then support and leverage the expertise of QUERI investigators over time. These evaluation centers can also be the foundation for further implementation or other research activities. Finally, the Implementation Training Hub sites funding opportunity is meant to provide long-term capacity building among QUERI investigators to train researchers and clinical leaders in practical implementation strategies that are not only of value to operational partners, but serve as novel methods for research studies (e.g., hybrid type III comparative implementation strategy studies). As a result, QUERI was invited to train Gold Status Fellows in implementation methods at the Diffusion of Excellence Gold Status Fellows in implementation Base Camp this month.
In this issue of QUERI eNews, we continue to pursue time-sensitive, rigorous evaluation and implementation work related to national policies impacting VA. In 2015, QUERI initiated several evaluations of the 2014 Veterans Choice Act Law; many of which led to findings that informed the VA Maintaining Systems & Strengthening Integrated Outside Networks (MISSION) Act which was passed in 2018. Key provisions of the MISSION Act include community care program implementation, expansion of virtual care (e.g., telemedicine), use of value-based payment models, enhancing access to and quality of care in VA medical service lines, and improving access to and quality of care in medically underserved areas. Examples of areas where QUERI investigators have made impacts in national policies related to the MISSION Act include evaluation of healthcare resource utilization among Veterans who receive organ transplantation within VA, Medicare, or both healthcare systems, expansion of peer support programs, telemedicine for women’s health, and caregiver support program expansion.
Overall, as in other U.S. healthcare systems and as articulated in recent reports on VA healthcare, including recent U.S. Government Accountability Office (GAO) reports, VA is evolving towards achieving the principles of a Learning Health Care System that the National Academy of Medicine has defined as the process by which “clinical informatics, incentives, and culture are aligned to promote continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience.” In concert with the Learning Health Care System, VA is also focused on becoming a High-reliability Health Care System, particularly in response to the recent GAO report highlighting the need for VA to deliver healthcare to Veterans optimally and consistently across different settings. High-reliability Health Care Systems empower frontline providers to lead performance improvement, where healthcare leaders encourage a culture focused on operations through preoccupation with failure, reluctance to simplify, deference to expertise, and commitment to resilience (Weick K and Sutcliffe K, 2015). QUERI is poised to achieve these high-reliability learning healthcare system goals as it continues to pursue impactful implementation and evaluation work towards implementation of legislative and clinical priorities to ultimately improve Veteran care.
Amy Kilbourne, PhD, MPH
Director, Quality Enhancement Research Initiative