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Response to Commentary

Achieving Substantial Real-World Impact on Veteran Care: From Innovation to Implementation

The VA Diffusion of Excellence and Innovation Ecosystem are some of the biggest efforts in the United States to foster innovation at the local level, and to take the best practices resulting from these efforts to national scale. In his commentary article, Dr. Vega describes the goals of the Diffusion of Excellence and Innovation Ecosystem, which are to empower frontline providers to think "outside the box" in order to solve common problems that vex large healthcare systems, while at the same time giving participating providers critical leadership experience in quality improvement. QUERI is actively partnering with the Diffusion of Excellence and Innovation Ecosystem, bringing to the table deep knowledge regarding evidence-based implementation strategies to help take these best practices to the next level.

Despite the success of these initiatives, more efforts are needed to hand off innovations for further study and implementation. Innovations generated through the Innovation Ecosystem, as well as through VA research funding, require further development and adaptation for successful implementation in real-world practice so that Veterans may benefit. Without attention to the strategies that encourage both implementation and sustainability, many effective clinical treatments will never reach the patients who can ultimately benefit from them. Greater attention is needed toward feasibility, fidelity, and end-user acceptance during treatment development and testing, as well as toward post-trial implementation strategies that ensure Veterans obtain quick access to the most effective treatments.

To this end, VA's Chief Research and Development Officer recently commissioned the Research to Real-World (R2R) workgroup, whose mission is to develop recommendations that lead to substantial real-world impacts of research. R2R includes representatives from the Office of Research & Development (ORD), Office of Academic Affiliations (OAA), VHA Reporting, Analytics, Performance, Improvement, and Deployment (RAPID), Clinical Operations (10N), Diffusion of Excellence, and the VA Innovation Ecosystem. The goal of R2R is to ensure that Veterans benefit from advances being made across the spectrum of VA research, ranging from genomics and other advancements in the basic sciences, to rehabilitation and technology, and clinical and implementation research.

The workgroup ultimately wants to encourage researchers and practitioners in the field to work together and develop novel treatments or interventions that have a direct benefit for Veterans. As with the Diffusion of Excellence and Innovation Ecosystem, researchers can benefit from working directly with other practitioners and Veterans in developing novel treatments, thus enhancing the "pull," or ownership of the discovery and implementation process, as opposed to the more top-down "push" of evidence-based practices into routine care. Many of these innovations in turn can be further developed through rigorous implementation and evaluation as they are scaled up and spread via randomized designs. QUERI is currently working on a new funding opportunity to support implementation and evaluation of the national rollout of Gold Status best practices selected by VHA leadership through the Diffusion of Excellence Initiative.

Partnerships with the Diffusion of Excellence and Innovation Ecosystem can also help researchers disseminate and translate their discoveries to wider audiences, particularly by adopting measures that are similar to those used by clinicians and VHA operations leaders to assess impact on patient care and return on investment. In a similar effort, ORD and HSR&D updated their impact metrics to comprehensively assess productivity (e.g., technology transfer—including number of invention disclosures), stakeholder involvement (e.g., communications to key decision-makers), market reach (e.g., number of providers adopting intervention, number of patients receiving intervention beyond the study), and policy change (e.g., whether interventions were adopted by national organizations or led to new legislation).

Finally, QUERI and the Diffusion of Excellence are teaming up to promote funding, training, and career development opportunities in innovation, product development, and implementation science. These opportunities focus on clinician career paths that encourage problem-focused or practice-based research (e.g., Learning Healthcare System) through greater partnerships with researchers to address common, high-priority health goals. Most recently, QUERI is establishing Implementation Training Hub sites to provide practical implementation skills to the DEI Gold Status Fellows.

Ultimately, researchers and clinicians benefit from the strong partnerships forged through the establishment of the Innovation Ecosystem, which combines a top-down with a bottom-up approach to innovation and implementation—an approach that seeks both to reduce the research-to-practice gap and to deliver substantial real-world impact of research on Veteran care.