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Director's Letter

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