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FORUM - Translating research into quality health care for Veterans

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The field of implementation science has grown exponentially in the past decade, but the "Holy Grail" of reducing the time from a research finding to adoption in routine care remains elusive. While researchers have offered dozens of implementation models, theories, and frameworks, few outline specific pathways or strategies for accelerating the movement of research from the academic shelf into the hands of patients and practitioners. Specific strategies that enhance quality improvement and implementation sustainability are vital for frontline providers who ultimately hold the key to sustaining evidence-based practices (EBPs).

QUERI is a leader in these efforts. The largest national network of implementation experts devoted to the rapid deployment of EBPs into routine care, QUERI's goal is to have more front-line providers implementing EBPs using quality improvement strategies. We have seen great progress towards our goal; through a national network of 15 QUERI programs, VA has implemented over 50 clinical EBPs in 2016 alone. Recent examples include integrated pain management primary care models, telehealth for PTSD, Hepatitis C testing and management, and homelessness peer support programs, to name a few. QUERI was able to achieve this more rapid uptake of EBPs because QUERI required each program to implement a quality improvement strategy that improved the uptake of evidence-based practices, and to work with independent national clinical operations partners to launch EBP uptake.

Quality improvement strategies are the "how" of implementation science. Without the specific tools or methods deployed at the organization level to help providers adopt effective practices, implementation cannot happen. Moreover, quality improvement strategies are vital to "scale up and spread" initiatives in order to maximize fidelity to the EBP and sustainability. Quality improvement strategies must involve state of the art methods geared towards provider engagement, ownership, and empowerment—methods drawn from organizational psychology, management, economics, sociology, and other fields. To this end, each of the15 QUERI programs serves as a "laboratory" that actively tests established quality improvement strategies, including audit and feedback, Facilitation (provider strategic thinking), and Lean, as well as new strategies such as "unlearning" or de-implementation of low-value care practices.

This issue of FORUM showcases cuttingedge implementation science from the QUERI centers and related quality improvement initiatives in VA. Notably, investigators from the Precision Monitoring to Transform Care (PRIS-M) QUERI Program moved from ascertainment of Big Data to establishing a national quality improvement strategy for stroke care. Similarly, investigators from the Coordinated Care QUERI in greater Los Angeles applied evidence-based quality improvement strategies (EBQI) to facilitate adoption of patient-centered medical homes, resulting in a crucial leap forward in developing strategies that improved provider engagement by reducing burnout. The QUERI for Team-based Care demonstrated the effectiveness of front-line provider-centered quality improvement strategies, using both external facilitators and embedded internal facilitators to enhance the uptake of primary care-mental health integration. More recently, VA national leaders challenged QUERI to take the program to the next level—by working to develop a cadre of tested quality improvement strategies that can be used to scale up and spread the highest priority initiatives. In doing so, QUERI must pay careful attention to input and involvement from multiple stakeholders, especially from front-line providers. While quality improvement strategies such as Facilitation involve front-line providers at the beginning, in most cases, the evidencebased practice is still implemented from the top down, highlighting the need to include stakeholders from all levels in the process.

This year, QUERI funded a national evaluation of the Diffusion of Excellence initiative that seeks to garner ideas of best practices from the "bottom up" (beginning with frontline providers) and select the most promising ones via a "shark tank" format. This approach complements QUERI's focus by working with providers to realize the value of local experience, while at the same time applying implementation science to learn which quality improvement strategies are best for scaling up and spreading promising practices nationally. The Diffusion of Excellence platform will also provide opportunities to deploy quality improvement strategies from the ground up, determining which ones are most likely to lead to spread of effective practices across different settings.

Ultimately, front-line providers won't adopt an effective practice unless they find it of value to their day to day practice. The most promising quality improvement strategies are derived from underlying theory but also actively involve providers as key stakeholders from the beginning. For example, allowing front-line providers to adapt EBPs encourages ownership of the practice by the providers, a key motivator for successful longer-term adoption. Quality improvement strategies such as Replicating Effective Programs include steps that embrace adaptation but more work is needed to test their effectiveness in enhancing outcomes and sustainability. Finally, promoting positive deviance from the bottom-up is crucial because often the best ideas come from front-line providers.

What will it take to sustain the scale up and spread of evidence-based practices? Through QUERI and HSR&D, VA aims, with input from front-line providers and national leaders, to inform research and practice that will: 1) develop common national outcomes metrics to measure implementation effectiveness; 2) identify factors that drive variations in EBP uptake and learn from "positive deviant" sites (including those with promising practices ready for national implementation); 3) develop and deploy tested quality improvement strategies for sustaining EBPs; and 4) determine the return-on-investment of implementation strategies so they can be resourced and used across different EBPs. To this end, we can move from theory to practice and ultimately, enable research to reach the providers and the Veterans they serve more efficiently and effectively.

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