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Amy Kilbourne, PhD, MPH, Director of QUERI

Director's Letter

Veterans deserve high-quality, effective, and safe care. One of VA's priority goals is to improve the quality and safety of care delivery. As an integrated health system, VA is in a unique position to promote organizational and cultural changes necessary to achieve these goals. VA is also a national leader in the Choosing Wisely initiative, a program designed to de-implement low-value practices and overuse of unnecessary care that might have unintended negative effects on health. However, while Choosing Wisely identifies targets for de-implementation, it does not speak to what strategies may help achieve this goal.

Several of our QUERI programs are conducting pioneering initiatives focused on strategies to improve quality and safety of healthcare for Veterans. Notably, the Improving Safety and Quality QUERI is helping develop effective de-implementation strategies that mitigate unintended consequences or inappropriate tests or overuse of services. Combating Antimicrobial Resistance through Rapid Implementation of Available Guidelines and Evidence (CARRIAGE) is addressing the growing public health crisis of antimicrobial resistance by improving on effective implementation strategies. MedSAFE QUERI is focused on optimizing medication use with decision support and provider networks in order to improve management of high-risk medications that require routine monitoring. The VA Healthcare-Associated Infection Prevention Network (VHIN) is a QUERI partnered Evaluation Initiative with the National Center for Patient Safety (NCPS) that will help facilitate the rapid implementation and evaluation of evidence-based infection prevention practices nationally.

These QUERI programs are also working at the intersection of implementation science and quality improvement, drawing these seemingly parallel universes closer together. Traditionally, quality improvement involves the analysis of healthcare performance and systematic efforts to make it better, whereas implementation science determines how to promote provider behavior change in the context of organizational constraints. Both fields strive to support more frontline providers that are implementing and sustaining effective practices. QUERI implementation strategies focus on mitigating common barriers that providers encounter, including limited tools or training, competing demands, organizational misalignment of priorities, and lack of effective practices suitable for the "the real world." QUERI implementation strategies, such as evidence-based quality improvement, also work to align bottom-up as well as top-down support, highlight the return-on-investment for leadership, and empower frontline providers to "lead from the middle," enabling them to own the improvement at their site.

People won't use something unless they want to, and allowing providers to adapt effective practices allows ownership, a motivator for adoption. Several implementation frameworks include steps that embrace adaptation, but more work is needed to test their effectiveness in enhancing outcomes and sustainability. Promoting positive deviance from the bottom-up is crucial because the best ideas often come from frontline providers, and as Dale Carnegie has said, "Let the other person feel that the idea was his or hers." Ultimately, QUERI implementation strategies can help organizations, such as the VA healthcare system, promote overall quality improvement.

Amy Kilbourne, PhD, MPH
Director, Quality Enhancement Research Initiative