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VA has launched several initiatives to empower and expand the innovative work of its 325,000 person strong workforce.
- The VA Diffusion of Excellence Initiative's (DEI) mission is to identify clinical and administrative innovations adopted by frontline VA staff—and to spread those innovations across VA's 1,000+ sites of care.
- A related initiative is the peer-reviewed Spreading Healthcare Access, Activities, Research, and Knowledge (SHAARK) QUERI Partnered Evaluation Initiative (PEI), a multidisciplinary team of QUERI investigators who worked with DEI leaders to develop a mixed-methods evaluation of the DEI.
- Applying implementation methods and science, the SHAARK PEI is working to not only evaluate the work of the DEI, but also to help achieve the DEI's goal of rapidly spreading innovations across the VA system.
In October 2015, VA's Under Secretary for Health (USH) initiated the VA Diffusion of Excellence Initiative (DEI). The DEI has been institutionalized as part of the broader VHA Innovation Ecosystem within the Veterans Health Administration. The objectives of the DEI are to: 1) empower employees to develop promising practices in care and administrative processes; 2) institutionalize the process for implementing and spreading promising practices; and 3) minimize negative variation in promising practices across VA.
The DEI process begins by soliciting promising clinical or administrative practices from frontline VA staff that address key priorities of the VA Secretary and USH. Submitted practices must have been successfully implemented with positive results at one or more VA medical centers. So far, 1,676 practices have been submitted for the first four rounds of solicitations and have covered a wide range of topics from a computer icon for employees to quickly and easily report their annual flu shot, to tracking staff competencies in environmental management services, to enhancing delivery of prosthetic services, to enhancing the role of chaplain and mental health services in reducing suicide risk among Veterans.
Submitted applications are reviewed by subject matter experts and frontline staff who select approximately 20 finalists per round. Finalists create a short video that introduces their practice followed by two-minute presentations to VA facility and network directors who volunteered to be "Sharks" during a virtual "USH Shark Tank." The Sharks make bids for the opportunity to implement a practice. Bids are often multi-faceted and have included a wide range of support from dedicated personnel time to travel support. The winning Shark is provided with facilitated implementation support to get the practice in place at their facility within six months. A Governance Board (comprised of the USH, Deputy USHs and other senior VA leaders) designates winning practices as "gold status practices." One to three Sharks and their facilities are chosen per practice. Following selection, a two-day VA Diffusion Summit is convened with "gold status facilities" (facilities that submitted the gold status practices) and "implementing facilities" (facilities whose Sharks won bids to implement the gold status practices). These teams work together with their implementation facilitator to develop implementation plans and materials.
An overarching goal of DEI is the development of plans and strategies to spread practices that are successfully implemented at new facilities. These efforts involve a range of potential options including developing tools to "market" the practices to facilities looking for potential solutions to challenges, partnering with VA program offices to facilitate implementation, and receiving direct support from the DEI. This support aims to place a practice in all appropriate facilities. In sum, the DEI seeks to support the potential for frontline staff to provide bottom-up solutions that may be implemented with the assistance of top-down support from high-level VA leaders—solutions aimed first and foremost at improving care and services for Veterans while enhancing the experience of patients, caregivers, and employees.
A multidisciplinary team of QUERI investigators from the Durham, Ann Arbor, and Bedford/Boston HSR&D Centers of Innovation actively partnered with DEI leaders to develop a mixed-methods evaluation of the DEI, anchored by implementation science theory. The result is the peer-reviewed Spreading Healthcare Access, Activities, Research, and Knowledge (SHAARK) QUERI Partnered Evaluation Initiative (PEI).
The SHAARK PEI seeks to better understand: 1) the decision process of VA facilities and individuals related to participation in DEI; 2) criteria used by facilities in deciding whether to bid on a "gold status practice"; 3) barriers and facilitators to implementation of practices; and 4) factors that influence spread across VA. The Consolidated Framework for Implementation Research (CFIR),1 Theory of Organizational Readiness for Change,2 and Theory of Diffusion of Innovation3 guide the SHAARK evaluation.
The SHAARK team is conducting semi-structured interviews with individuals who developed gold status practices (known as "gold status fellows"), individuals with operational responsibility for implementing gold status practices during the six-month facilitated implementation period (termed "implementing fellows") and other implementation team members, VA directors who are eligible to be "Sharks," and individuals who facilitate implementation. These interviews provide insights into reasons for developing practices, the process of applying to have a practice spread through the DEI, and how and why facilities decided to bid on the practice in the Shark Tank and then adopted it as part of their everyday workflow. We are also able to gain an in-depth understanding of practice features that may impact initial implementation and spread. Interviews are supplemented by structured observations of VA Diffusion Summits, virtual focus groups with Sharks, and surveys of Sharks.
The 110 interviews that have been conducted to date have offered a number of key insights. For example, VA facilities were motivated to participate in the Shark Tank process when staff communicated an issue to the potential Shark, read about an effective practice in published literature, and/or desired to improve performance measures. To successfully implement and sustain a new practice, it is important for key staff members to recognize a need to implement a practice. Furthermore, the practice needs to be compatible with existing workflows and have sufficient resources (e.g., dedicated time, space). External facilitation provided by DEI and in-person meetings, starting with the Summit, to develop and execute implementation plans were key facilitators to work around or address potential implementation barriers.
A significant area of interest impacting all stages of the DEI process is how and why facilities make decisions to adopt promising practices and innovations. In addition to the methods described above, we will be working with VA facility directors and frontline staff to better understand how they categorize practices by key characteristics such as expected outcomes, stakeholders who may benefit, and the impact on workflow.
Lastly, we are evaluating the nature and magnitude of practice spread across VHA. In collaboration with the VA Office of Strategic Integration and the DEI project management team, we are helping to evolve systems through which facilities report implementation activities and analyze implementation data. As of January 2018, VA medical centers across the nation have initiated approximately 774 projects to implement the 37 gold status practices identified through the first three rounds of the DEI process. Early observations indicate that practices with the broadest dissemination share several characteristics, including a longer time since introduction through the DEI, a concretely-defined tool, a clear national VA leadership expectation for implementation, and, finally, a focus on high-priority VA goals. To explore potential factors that may also impact practice spread, we are combining information on spread with available VA data on employee workplace perceptions, patient satisfaction, and quality of care.
A core goal for SHAARK, as with the QUERI program, is making a practical and positive impact within VA, including the operation of the DEI. The SHAARK team is developing decision grids to convey practice features that may impact Sharks' decisions to bid on practices; developing methods to help facilities quickly identify potential solutions to organizational challenges; and helping to identify and ensure involvement of key stakeholders throughout the innovation process. Multiple components of the QUERI program, as well as SHAARK PEI, are utilizing expertise in evaluating evidence, identifying implementation strategies, and selecting data-driven measures of innovation impact. These components complement our DEI partners' expertise in identifying and spreading practices to: 1) evaluate evidence behind potential DEI practices; 2) increase knowledge of frontline staff about implementation science, implementation strategies, and evaluation; and 3) provide help linking practices and VA data.
As the largest integrated delivery system in the United States, VA seeks to empower and expand the innovative work of its more than 325,000 employees to provide high-quality, Veteran-centric care across more than 1,000 sites of care. The DEI seeks to be a catalyst for identifying and spreading these innovations. Applying implementation methods and science, the SHARRK PEI is working to understand how to maximize DEI impact and achieve its goal to rapidly spread innovations across the system and best serve our nation's heroes.
- Damschroder LJ, et al. "Fostering Implementation of Health Services Research Findings into Practice: A Consolidated Framework for Advancing Implementation Science," Implementation Science 2009; 4:50.
- Weiner BJ. "A Theory of Organizational Readiness for Change," Implementation Science 2009; 4:67.
- Rogers EM. Diffusion of Innovations. 4th ed. New York, NY: The Free Press; 1995.