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Transformation and QUERI

The fundamental question at the heart of the debate over health care reform is how to redesign a dysfunctional health care system so that it promotes quality and value. Watching this debate, it can be tempting to congratulate ourselves for the many ways that VA is ahead of the private market--for example, in our ability to measure and reward performance, our primary-carebased outpatient system, and our electronic health record. But as Joe Francis reminds us in his commentary, the challenges facing VA are no less daunting. We need to adapt to meet the needs and preferences of a new generation of young Veterans while maintaining our commitment to aging Veterans from earlier wars. To do this, VA needs to transform itself to become a high-quality, efficient, patient-centered system. For those of us involved in the QUERI program, which was designed to speed the uptake of better practices in VA, the call for such a transformation poses two questions. How can QUERI help facilitate that transformation, and how might this transformation require changes to QUERI itself ?

Change Lessons from the First Ten Years of QUERI

The first ten years of QUERI taught us many of the lessons about change observed by Dr. Francis. Change depends on people and relationships; it cannot be achieved simply by disseminating data or directives; success often depends on facilitation and on the local conditions; and it usually takes longer and costs more than we hope.¹ Three factors, however, create new opportunities for change in VA and for QUERI. The first is the new leadership under Secretary Shinseki, since commitment of leadership is one of the essential factors in any successful change.² The second is consensus on a direction for change. The Universal Services Task Force recommendations provide a road map of what specific changes are needed, and many of these involve areas studied by QUERI-- implementing new models of care, expanding telehealth and Web-based interventions, and improving coordination across providers. Finally, the expanding work of the Systems Redesign initiative has created opportunities to partner with a VA-wide effort working at the network and facility level to address high priority process improvements for VA.

Systems Redesign and QUERI offer complementary approaches for how to speed change in the health care system. In Systems Redesign, engineering approaches such as process mapping, making small tests of change, applying "lean" principles to eliminate waste, and collaborative learning have succeeded in improving access and reducing waiting times and they are expanding to address new administrative and clinical issues. Elements of the QUERI approach, however, are essential to tackle the complex processes of improving care in chronic disease. The clinical and research expertise within QUERI is needed to decide which changes are most important. For example, the work of the Diabetes QUERI identified "improvements"that provide little benefit (tight glucose control in older patients) and those that are clinically most important (improving poorly controlled blood pressure). Implementation science can help understand the barriers and facilitators at the patient, clinician, practice, and system level that go beyond simple process improvement. The QUERI program can more easily support solutions that would be hard to develop through incremental changes and rapid process improvement--for example, the multi-year projects to develop the infrastructure for the TIDES depression care management model or to design the CARTCL catheterization registry. Finally, the research expertise within QUERI has been essential for refining clinical databases so we can tell whether our efforts are succeeding.

Key Learnings from Systems Redesign

There are important opportunities, however, for QUERI to learn from Systems Redesign to develop interventions that are more responsive to the needs of our stakeholders and more sustainable. Attention to engineering principles and efficiency can identify improvements that do not require new resources. Second, letting stakeholders determine their own priorities for change produces more effective engagement than when a "solution"appears to have been developed at a distance by researchers. Finally, learning from best performers within the system may help convince others that the solutions are feasible and sustainable. Several QUERI Centers, including Stroke and Chronic Heart Failure, have begun to collaborate on systems redesign projects to bring the strengths of both approaches together and to foster cross-program learning. The four new Veterans Engineering Resource Centers (VERCs), funded under the Systems Redesign initiative, will provide new avenues for collaboration between research and operations. QUERI will focus on additional ways to foster closer and more transparent collaboration with all of our health system partners, such as Office of Quality and Performance and Office of Patient Care Services.

A popular Dilbert cartoon notes, "Change is great--you go first."It is to the credit of VA that so many parties are "going first," readily embracing the call to improve the care we deliver and the systems in which we work. It will be our challenge to see that we are all pulling together toward the common vision of a Veteran-centered, forwardlooking, high-quality health care system.

References

1. Stetler CB, Mittman BS, Francis J. Overview of the VA QUERI and QUERI theme articles: QUERI Series Implementation Science 2008, 3:8.
2. VanDeusen Lukas C, et al. Implementation of a Clinical Innovation: The Case of Advanced Clinic Access in the Department of Veterans Affairs. Journal of Ambulatory Care Management 2008. 31:94-108.