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Response to Commentary

Aligning Forces for Implementation

Implementing evidence into care for patients and then sustaining that implementation is arguably our biggest challenge in health services research. Much of VA's implementation science has been led and conceptualized by VA HSR&D and QUERI investigators. Our embedded intramural research program ensures that we as researchers address topics that are of importance to the care of Veterans and to our VA health care delivery system. Our career development award program creates a human capital pipeline of talented scientists who develop their research agendas within the rich data environment and multiple delivery settings of the Veterans Health Administration (VHA). The graduates of these programs often are retained in VHA to provide mentorship to the next generation of researchers, and to provide research, educational, and clinical leadership to VHA.

Health Care Delivery System Partnerships

HSR&D explicitly recognizes and encourages partnership with the health care delivery system through its Center of Innovation (COIN) infrastructure program as well as funding mechanisms such as the Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative. The latter requires operational partners and researchers to interact throughout the research development and implementation process. Through the QUERI Evidence Synthesis Program, we ensure that our evidence reviews address important topics for our patients and our health care delivery system. The Evidence Synthesis Program also provides an opportunity to blend VA and non-VA research evidence, so that we can learn from other delivery settings, and vice versa. Implementation of this evidence into best VA clinical practice is in turn facilitated by the HSR&D QUERI program, which, as Dr. Kilbourne notes in her commentary article, is the largest network of implementation science experts in the United States. VA, as the largest integrated health care delivery system in the nation with a global fixed budget, directly benefits from innovations in health care delivery that it can deploy directly into practice. So, an effective intervention developed by researchers that reduces infection rates in the intensive care unit, in addition to improving quality, also leads to shorter lengths of stay, and directly helps the financial bottom line of the health care delivery setting rather than an insurance company's profits. Furthermore, implementing preventive health interventions for Veterans, such as cardiac risk factor modification, allows VA to benefit from near-term investments that yield long-term benefits in morbidity and mortality, because our patients do not lose their VA "coverage." Our mission and expectations from Congress, Veteran advocacy groups, and the public provide additional pressures for VA to deliver access to high quality care. These pressures are unique to VA.

Research funding agencies such as the Agency for Healthcare Research and Quality and the National Institutes for Health do not have a health care delivery system, so while they produce state-of-the-art science, they have far fewer opportunities for implementation. The Centers for Medicare and Medicaid Services, while financing a large proportion of U.S. health care, does not have a formal embedded research program that it can deploy.

Implementation of Research Into Practice

Despite the alignment of incentives in VHA, implementation of best evidence into best practice is not as rapid or seamless as we would wish. Intriguing models of combining top-down leadership with bottom-up engagement of front-line staff are the next wave of experiments in speeding implementation of research into practice. Multiple Houston PACT CREATE projects are experimenting in this vein. In one project (CRE 12-035: Identifying and delivering point-of-care information to improve care coordination), we brought to primary care the Productivity Measurement and Enhancement System (ProMES), an empirically effective, structured focus group methodology from the discipline of industrial/organizational psychology based on motivational theory. In this approach, an already existing work team systematically identifies organizational objectives and develops clear, accountable performance measures, which are prioritized and weighted by their contribution to overall quality.

The research method and collaborative partnership with VISN 12 leadership through the CREATE development process, guided by The Practical Robust Implementation and Sustainability Model (PRISM), facilitated strong engagement by front-line staff and local leadership. ^1,2 We are evaluating applications of ProMES now at multiple facilities and CBOCs in two VISNs, and we have received positive feedback about sustaining the project after research funding ends at several sites, perhaps due to engagement of partners at multiple levels from front line to network. We will propose a formal assessment of the sustainability of this intervention as part of an implementation evaluation.

VHA is a leader in implementation science and continues to innovate with implementation methods; these innovations in turn benefit non-VA health care settings. This is one of the many ways VA is able to achieve the aims of a learning health care system.³

References

1. Feldstein, AC, Glasgow RE. "A Practical, Robust Implementation and Sustainability Model (PRISM) for Integrating Research Findings into Practice," Joint Commission Journal on Quality and Patient Safety 2008; 34(4): 228-43.
2. Hysong SJ, et al. "Study Protocol: Identifying and Delivering Point-of-care Information to Improve Care Coordination," Implementation Science 2015; 10:145.
3. IOM (Institute of Medicine). Best Care at Lower Cost: the Path to Continuously Learning Health Care in America. Washington, D.C.: The National Academies Press; 2013.