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Amy Kilbourne, Ph.D., M.P.H., Director of QUERI

Director's Letter

QUERI: Now More than Ever

The goal of the VA Quality Enhancement Research Initiative (QUERI) is to improve Veteran health by supporting the more rapid implementation of effective treatments into practice. Since 1998, QUERI has achieved this goal as a field-based program comprised of Centers and projects that primarily focus on conditions that contribute to the major causes of morbidity and mortality among Veterans. Providing an essential combination of scientific rigor and bi-directional partnerships with VA operations, QUERI has been integral to VA's efforts to transform its healthcare system, thereby improving the health and quality of care for Veterans. To this end, QUERI continues to adapt to changing VA priorities, taking a leading role in identifying opportunities for quality enhancement in VA and beyond in the era of the Learning Healthcare System.

Now more than ever, QUERI remains an essential component to VA care. In the wake of highly-publicized problems with healthcare access and quality, VA is undergoing an unprecedented reorganization, notably with the passing of the Veteran's Choice Act and a national reorganization through the MyVAinitiative. Subsequently, VA priorities are being realigned and many national programs (including QUERI) received funding cuts to provide additional support for these new initiatives.

How is QUERI responding to VA's transformation? First, QUERI serves as a trusted partner to providers and clinical leadership, applying a deep knowledge of evidence-based care and improvement science to support VA in the adoption of new initiatives into routine clinical care. As with many new initiatives, VA's reorganization will likely have intended and unintended consequences on access, organization, and financing of care for Veterans. Many initiatives do not achieve their desired goals because of the lack of effective strategies to overcome barriers to implementation, including competing demands on frontline providers to implement new practices, and variations in organizational characteristics or capacity. QUERI investigators will be essential in helping VA unpack the uptake of the Veteran's Choice Act and related initiatives over time, and in identifying and testing optimal sustainability strategies across different practice settings.

Second, QUERI will need to further adapt and focus more on cross-cutting issues, with an eye towards the development of methods, infrastructures, and products that support operational partners in improving VA healthcare. In doing so, QUERI can play an essential role in VA's Blueprint for Excellence (e.g., Goal #7: decreasing the time from the publication of research demonstrating clinical effectiveness of an intervention deemed a national VA priority to its use by VA providers). QUERI also may need to support the de-implementation of ineffective or lower-value initiatives, especially those that contribute to the research-to-practice gap. Working with the VA Office of Research & Development, QUERI has played an integral role in promoting efficiencies in the research pipeline, notably through the development of expedited, peer-reviewed funding and approval mechanisms (e.g., RISOMEs, Partnered Evaluation Centers) that support national evaluation efforts.

Finally, supporting VA's transformation will require continued investment in a critical mass of implementation-savvy scientists, especially those who can lead innovation at the earlier stages of the efficacy/effectiveness research pipeline (e.g., advanced analytical techniques involving measurement science, provider decision-making) and forge new partnerships (e.g., regional Community Veteran Advisory Councils). The Spinal Cord Injury (SCI) and Polytrauma & Blast-Related Injury (PT/BRI) QUERI Centers featured in this issue promoted this concept of "designing-for-implementation," given the need to more rapidly discover and deploy evidence-based practices for the vulnerable groups of patients they serve. Thus, both SCI-QUERI and PT/BRI-QUERI are poised to help usher in the next generation of new practices and technologies.

VA's recent transformation involves major changes of a magnitude not seen in more than a generation. These changes do not represent business as usual, and QUERI will need to further adapt to be an essential partner to VA. As VA's engine for promoting a successful learning healthcare organization, QUERI is a model for deploying rigorous improvement science that supports front-line providers and clinical leaders in their mission to improve healthcare for Veterans. By staying grounded in research and actively engaging in partnerships with operations, QUERI will continue to play a major role in informing the uptake, sustainability, and value of new initiatives to ultimately improve the quality and outcomes of care for Veterans.

Amy Kilbourne, Ph.D., M.P.H.

Director, Quality Enhancement Research Initiative