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Director's Letter

Cultivating the Next-Gen Workforce in Learning Health Systems

Amy Kilbourne, PhD, MPH, Director of QUERI

At our last QUERI strategic meeting, one theme that we have not heard as much about in the past, but has become more prominent recently, was de-implementation. Specifically, how can QUERI determine and communicate what is NOT working for patients so that providers can focus on more high-value care? The theme was also highlighted in the recent Shark Tank call from the Diffusion of Excellence, along with workforce wellbeing and similar priorities.

There is only so much time in the day to get all of the work done that we want to do. And each time QUERI elicits input from our leaders, the priorities seem to grow and challenge us to think more broadly on system-level impacts that improve access and efficiency, while at the same time avoiding provider burnout and turnover in a tight labor market. Not surprisingly, the National Academy of Medicine’s report “The Future of Health Services Research: Advancing Health Systems Research and Practice in the United States” (2018) strongly emphasized that investigators should focus on addressing the complex, multilevel problems facing healthcare systems to improve quality, promote health equity, and make a public health impact.

To help prioritize and route scientific investments, QUERI, with the support of VHA leadership, helped to establish the Evidence-based Policy Subcommittee, which reports to the Undersecretary and serves as a primary forum for helping to identify, recommend, and route top healthcare priorities for further evaluation in QUERI or elsewhere. While designed to help VA fulfill core requirements of the Evidence Act, the Subcommittee can potentially leverage resources across the system and reduce duplication of efforts. For example, the newly funded QUERI Evidence-based Policy Centers will take on some of these cross-cutting priorities, while others might be routed to Research, to other VHA program offices, or to VA Central Office (VACO) for enterprise-wide support.

However, a more comprehensive infrastructure needs to be in place to support the required data, processes, people, and policies needed to sustain national implementation and evaluation studies to address these top priorities. Many areas such as access, workforce, and virtual care span conditions, program offices, and service settings – and call for more system-level and nuanced solutions beyond a single intervention. VA’s Office of Research & Development (ORD), with its recent announcement of an enterprise-wide approach to research, is striving to increase the real-world impact of scientific investments through what has been termed “actively managed portfolios” (akin to problem-focused research, or priorities based on healthcare operational needs). A proposed example is precision oncology.

ORD’s enterprise-wide approach can be enhanced with greater investments in informatics infrastructure, as well as an appropriately trained scientific workforce. The Agency for Healthcare Research and Quality (AHRQ) Learning Health System (LHS) Competencies recently adopted by the HSR&D Advanced Fellowship program provides a roadmap for a system-based workforce for ORD. Examples of LHS core competencies include improvement and implementation science, informatics, systems science, ethics, and community engagement. These competencies also align nicely with the Quintuple Aim goals of improving population health, healthcare consumer and workforce experiences, reducing costs, and improving health equity. Many of these skills were on active display among our QUERI investigators who presented at the AcademyHealth Annual Research Meeting (see related article in this issue).

As nearly three-quarters of all U.S physicians receiving training in the VA healthcare system, VA is also poised to become one of the largest single trainers and employers of an LHS-savvy workforce to directly address complex healthcare problems through a multi-disciplinary, partner-driven approach. Investigators adept in LHS core competencies are needed to not only improve VA care, but to retain and empower a national scientific workforce that ultimately informs improved health for Veterans.

Amy Kilbourne, PhD, MPH
QUERI Director

Melissa Braganza, MPH
QUERI Deputy Director