» Back to Table of Contents
A key marker of a high-performing system is consistent and
reliable performance. By this measure, both VA and the U.S. health
care system have a long way to go. For a national system like VA,
with 168 facilities and thousands of outpatient clinics, achieving
more rapid spread of best practices and new innovations is a
serious challenge. Despite data confirming that average VA
performance is generally good relative to our peers, it isn't
consistently good everywhere in VA. In a time of increasing scrutiny of and skepticism
about VA, it is critical that we improve our ability to scale improvements across the
diverse VA health system.
VA has had some notable successes, in areas like colorectal cancer screening,
prevention of hospital-acquired infections, and integration of primary care and
mental health. In other cases, such as the recent implementation of primary care
patient-aligned care teams (PACTs), uptake across the many facilities has been
inconsistent, hampered by uneven commitment of local leadership and variable
staffing. The result is that the driving aims of the PACT initiative, improving patient
outcomes while reducing provider burnout, have not been fully realized. Underlying
these examples is the inevitable tension over when to disseminate a single, national
standard for practice and when to emphasize common goals but allow local facilities
and clinicians flexibility regarding how to achieve them.
Fortunately, VA and VA researchers have been ahead of the curve in thinking about
implementation as a discrete and specific process susceptible to scientific inquiry.
The Quality Enhancement Research Initiative (QUERI) was established in the late
1990's to tackle implementation in a number of high-priority conditions, and VA
researchers have been important contributors to the early field of implementation
science. As outlined in the articles in this issue, such work has identified factors critical
to implementing new practices and described measures to enhance spread.
The hard truth is that there is no single recipe for successful implementation. Plenty
of work remains for researchers to do, including helping to determine when a
practice is truly ready to be scaled up, how it may need to be adapted to different
environments, and how most effectively to facilitate the uptake in new settings.
David Atkins, MD, MPH, Director, HSR&D