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Crucial Opportunities for Addressing HAIs

I appreciate Dr. Roselle highlighting the pervasiveness of HAIs, thus demonstrating their critical importance and the need for both implementation and further research. I share his conviction that HAIs have finally gained the national attention of the public, policymakers, Congress, and funding agencies. This is a promising time when funding is finally being targeted to address questions of comparative effectiveness, including the broader definition favored by VA and AHRQ, which includes issues related to delivery systems, implementation, and reengineering.

As Dr. Roselle points out, HAIs are not unavoidable. HAIs are due to the practices and behaviors of everyone in health care settings. A complex adaptive systems framework suggests the concept of emergence. We find that success at one level precipitates new challenges at the next level. As effective programs develop and become systematized, just as in ecocycles, there is a creative destruction or reorganization phase. ¹

Hospitals that have tackled HAIs as an organizational change challenge, rather than continuing to delegate HAIs to the infection control program, are those that have seen dramatic reductions in MRSA and other HAIs and dramatic improvements in quality in other domains.² Partnering with facility and VISN leadership, and engaging teams of committed health care staff volunteers in owning, driving, and measuring change is effective, creative, and sustainable.

If anything, now is the time for even greater efforts to bring together operations leaders, clinicians, staff and researchers for more regular conversation, perhaps at regional and national meetings, in order for operations to help focus us on the important clinical and management issues that need further research because they are not easily solvable. VA should find opportunities to bring operations and researchers together, to apply their conceptual frameworks, develop new quick methods and evaluation methodology.

Dr. Roselle points out correctly that many of the specific questions regarding details of policy and how to implement them are not studied and remain open questions. However, the lack of evidence for many interventions should not delay action in improving health care processes and quality. Model health care systems like VA and Intermountain Healthcare have shown the value of focusing on identifying high prevalence conditions, describing variation in processes and eliminating that variation through quality improvement and information solutions. Effective managers do not wait for evidence. There is too much work to be done in transforming our health care systems and much of it needs to be done now.

I remain impressed that my colleagues in HSR&D have been tackling these difficult problems for a number of years, as the articles here show. In fact, one of the challenges in conducting such research in implementation science and system redesign is that our funding and publishing mechanisms remain too slow to fund thoughtful evaluations of important natural experiments and changes in systems that happen quickly. I agree that there is a keen need for further research in implementation science, effective organizational change strategies, and how to effectively integrate information and communication technology into workflow and practice. Some of the many recent VA innovations in operations — with formation of the VA Systems Redesign Office and Steering Committee, and forming and funding the VA Engineering Resource Centers — are important steps.

Dr. Roselle also highlights that the engagement of other specialties is needed to truly make a difference. The Pittsburgh VAMC showed the value of bringing expertise in engineering and social sciences to bear in driving organizational change to redesign their processes and engage staff hospital wide. I fully agree and have found that bringing informaticists, engineers, cognitive scientists, communications specialists, sociologists, and many other disciplines together to tackle important implementation science problems is not only fulfilling, but brings cutting edge methods to bear and creative solutions to previously "unsolvable" problems.

Further, there is a call for immediate new strategic directions in rethinking how computational technology can best support cognitive processes and decisions in a fundamentally different information system that will make effective, patient-centered care possible.³ The VA Consortium for Healthcare Informatics Research (CHIR) and Veterans' Informatics, Information and Computing Infrastructure (VINCI) are two important, multicenter VA initiatives designed to make electronic health information readily available for quality improvement and research, and fostering collaboration in new ground-breaking approaches not possible outside VA. Our VA informatics colleagues are actively planning the next generation of a new information system for VA.

These new directions for research, operations, care coordination, Office of Health Information (OHI), and all of VA are truly crucial innovations that bring together clinicians, managers, staff, researchers, and trainees to tackle tough problems together. I hope that VA leadership, Office of Research and Development (ORD), and all of us seek crucial opportunities for conversations together, find common ground, and work together collaboratively to design the new VA.

References

1. Frances Westley, Brenda Zimmerman, and Michael Quinn Patton. Getting to Maybe: How the World has Changed. Random House Canada, 2006.
2. Katherine Ellingson, Nancy Iversen, Jerry M. Zuckerman, et al, for the Positive Deviance MRSA Prevention Partnership. "A Successful Multi-Center Intervention to Prevent Transmission of Methicillin-resistant Staphylococcus aureus (MRSA)." The Society for Healthcare Epidemiology of America (SHEA) 19th Annual Scientific Meeting, March 21, 2009.
3. William W. Stead, Herbert S. Lin (eds), Committee on Engaging the Computer Science Research Community in Health Care Informatics. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Washington, D.C.: National Academies Press, 2009.