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Response to Commentary

Evidence-Based Implementation: Towards a Scientific Agenda for the Learning Healthcare System

VA is undergoing a major reorganization to transform the way it provides services nationally for its Veterans. This magnitude of change has not been seen in almost a generation. This transformation has already involved new policies such as the Veteran's Choice Act, which will change the role of the Veterans Health Administration (VHA) into serving as a payer as well as provider of health care for millions of Veterans nation-wide. Moreover, the reorganization under "MyVA" includes new initiatives designed to emphasize Veteran experience, access, and timeliness of care, shared VA services (e.g., combining health care and benefits customer service), and new models of care as emphasized in the VHA Blueprint for Excellence. These changes will require VHA to transform into a Learning Healthcare System, which the Institute of Medicine has described as one that is responsive to new information, adapts to implement more effective clinical practices, and is committed to an ongoing mission of excellence, supported by a culture of self-reflection and continuing education.

Lessons from Systems Engineering

To this end, there has been a growing interest in applying techniques used in systems engineering or systems redesign to operationalize essential elements of the Learning Healthcare System and improve quality. Many of these initiatives involve development of large national datasets to monitor and model care processes, but as Drs. Woodward-Hagg and Hemphill wisely observe, many efforts to implement Lean do not reach their full potential because of a lack of focus on promoting the cultural transformation necessary to improve care. This observation means that in addition to technical and data support, individuals on the front lines of care also need to feel valued and empowered to do their best. VA's Quality Enhancement Research Initia- tive (QUERI) and Health Services Research and Development (HSR&D) programs have responded to this need for best practices to promote the Learning Healthcare System through new initiatives and research that will help current Lean practices in VA. HSR&D, through the VA Office of Research and Development, is promoting several pathways to promote the science of the Learning Healthcare System, notably through initiatives that seek to further validate and discover new ways that health care providers and systems can change for the better.

Serving as a trusted partner to providers and clinical leadership, QUERI applies a deep knowledge of evidence-based care and innovative implementation science to support providers and clinical leaders in the adoption of research findings into clinical practice, asking crucial questions regarding the intended and unintended impacts of implementing new treatments or programs and the best strategies for speeding their adoption into practice. No other VA entity has specific responsibility for using scientific rigor to study the best implementation strategies for facilitating adoption of effective practices into routine care.

A close complement to Lean techniques, implementation science provides a systematized approach to identifying barriers and facilitators to system change, and uses this information to refine and test implementation strategies. Many of these strategies focus on methods to support providers in the use of a clinical treatment across different practice settings, including lower-resourced sites. In contrast to many quality improvement efforts, implementation scientists often use strategies aimed at helping providers adopt specific evidence-based practices (or in some cases, stop low-value practices). Common implementation strategies can encompass elements of Lean but also involve techniques such as facilitation, or guided efforts by internal or external organizational staff to support multiple levels of system change through provider or team-based coaching that focuses on leadership potential. ¹ Nonetheless, a comprehensive clearinghouse of effective implementation strategies and empirical evidence of their support for Lean and similar health systems transformation techniques remains elusive.

Informing Implementation Strategies

To this end, VA HSR&D and QUERI are supporting new initiatives in concert with recommendations from the Office of Management and Budget (OMB) that seek to inform the development of implementation strategies to ultimately promote a Learning Healthcare System. Key components include measurement science, operations research, point of care research, provider behavior, and randomized program evaluation and implementation to further support VA's transformation as a Learning Healthcare System. First, HSR&D is promoting research focused on measurement, which involves further developing methods for accurately assessing quality metrics that are tailored to Veteran needs. These new initiatives also focus on provider behavior, seeking to understand complex factors associated with variations in care through application of cognitive science, decision- making styles, and information processing to enhance performance improvement and adoption of evidence-based practices. In addition, HSR&D recently released a request for applications to promote operation re- search, which applies health systems data to develop mathematical models of health systems functions in order to improve health care timeliness and efficiency.

Finally, HSR&D and QUERI are involved in the support of rigorous evaluations of new programs such as the Lean Transformation Initiative Partnered Evaluation Center. OMB has strongly supported the use of rigorous methods to study and scale-up policies or interventions that have demonstrated effectiveness, or apply these methods towards assessing the effectiveness of new programs or policies of national priority for VA.

Randomized program evaluations of new programs or policies should focus not only on determining their impact on Veteran care but whether they were implemented as intended. They should ask not only "does the program work?" but also "what makes it work?" and "how can we make it work in the real world?" These evaluations ultimately produce greater return on the resources invested in implementing new programs. This approach to data-driven decision making has been referred to as "evidence-based policy," and VA and other federal programs are proposing greater investment in program evaluation, preferably involving systematic allocation of new programs using comparison groups to assess return-on-investment across programs. ² As a bridge between research and clinical operations, QUERI's role is the rigorous study and support of effective implementation or quality improvement strategies such as Lean that ultimately seek to empower frontline providers, promote transparency across organizational levels, and ensure that transformative initiatives are implemented to ultimately improve Veterans' care experience.

References

1. Bidassiee, B., Williams, L., Woodward-Hagg, H. et al. "Key Components of External Facilitation in an Acute Stroke Quality Improvement Collaborative in the Veterans Health Administration," Implementation Science 2015; 10:69.

2. Bridgeland, J. and Orszag, P. "Can Government Play Moneyball? How a New Era of Fiscal Scarcity Could Make Washington Work Better," The Atlantic July/August 2013.