VA is currently undergoing a reorganization that has not been seen since the 1990s. Spurred by the 2014 Veterans Choice Act in the wake of highly-publicized problems with access to care and wait times, the reorganization is based on two major reports that made sweeping recommendations for modernizing the VA healthcare system and delivery of services for Veterans. Key recommendations based on these reports included more local/regional decision-making control and more consistent use of effective practices. Taken together, these recommendations may represent a commonly perceived tension between the desire for more regional control versus top-down deployment of “best practices.”
QUERI has an unprecedented opportunity to support VA in maximizing the best of both worlds: implement effective practices that address clinical priorities AND encourage local facilities and VISNs (Veterans Integrated Service Networks) to tailor effective practices to their needs. The VHA FY2018 Performance Plan (http://vaww.visn1.va.gov/intranet/docs/misc/745236.pdf Available on the intranet only.) benchmarks VISN and facility leaders on scale-up and spread of best practices. VISNs are also having to manage an increasing proportion of community-based care, as well as adhere to new laws and policies mandating services related to suicide prevention and opioid use disorder. With their arsenal of implementation strategies and deep knowledge of VA patient care, QUERI investigators develop cross-cutting implementation strategies, many of which are featured in this issue. Through these strategies, QUERI supports more frontline providers with adopting and adapting effective practices in light of regional differences in barriers to care, and evaluating the results of those efforts to foster improved health and care for Veterans.
Success will require active partnerships among QUERI, VISNs, and key operations partners including the Diffusion of Excellence Initiative, among others. To accelerate these partnerships, QUERI launched a national request for applications to support implementation of effective practices specifically addressing VISN-identified healthcare priority goals. VISNs select which priority goal to focus on, and QUERI funds projects co-led by a VISN leader and implementation expert through a peer-reviewed process. VISNs will choose among the top priority goals (i.e., improving community care coordination, suicide prevention services, or opioid/pain treatment) which were selected by the VA National Leadership Council that were based on an extensive nomination process among VISN leaders (Directors, CMOs, and QMOs), facility Chiefs of Staff, and VHA national program leaders. QUERI national resource centers provide technical consultation in selection, tailoring, and evaluation of effective clinical practices that are aligned with these nationally-sanctioned priorities and are tailored to VISN needs.
Overall, the challenge for QUERI is to continue to ensure that their work is essential to VISNs as well as to the VA healthcare system overall. This means that each QUERI project should track return on investment for the facility leaders and make the business case for implementation of effective practices in the VISNs and beyond. Regional and national leaders will want to know how many Veterans benefit from the greater spread of effective practices, the total cost of implementing effective practices, and how it impacts provider engagement and productivity. Also, how much will it cost leaders to spread and sustain effective practices once QUERI is finished with the project?
Going forward, QUERI will need to ensure that it supports VISNs benchmarked to VISN leadership plan goals and national priorities – but with a direct line to national VHA priorities, using nationally established implementation strategies and institutionally-sanctioned effective practices. Our active partnership with the Diffusion of Excellence (DoE) also supports VISN efforts to enhance adoption and adaption of effective practices. Notably, DoE’s ability to tap into frontline provider intrinsic motivation to identify best practices can be leveraged by QUERI’s expertise in evidence review, evaluation methods, and implementation strategies to further support these providers in the scale-up and spread. In turn, DoE can help QUERI strengthen linkages to local leaders and innovators, and provide essential leverage in linking these efforts to national priority goals. These synergies will help maximize the impact of the collective work by DoE and QUERI toward improving Veteran care.
QUERI’s future will be leveraging of these strategic partnerships, locally and nationally, and helping to invest in implementation strategies that can support national priority goals towards greater consistency of high-quality care, while enabling local innovation and tailoring opportunities.
Amy Kilbourne, PhD, MPH