QUERI: Connecting Research and Patient Care

1. QUERI: Connecting Research and Patient Care David Atkins, MD, MPH Director, QUERI HSRD Field Based Meeting Indianapolis, July 2010

2. 3 Questions • What do we want to do? • What problem are we trying to solve? • How are we going to do it? • How do SR and IR approaches contribute to solutions? • Who is going to do it? • What structures and processes will help us work together?

3. What Is the Problem ? • New research takes too long to get adopted • Too much variation in the healthcare system • Reliability, efficiency • Research is often not aligned to address critical problems for health system • Large programs being rolled out without adequate planning to maximize effectiveness and learning

4. How do we speed,spread, and sustain change in a complex healthcare system?

5. “Change” as Gardening

6. Gardening • Crop = Desired change to be implemented • Climate = local context • Seed = Implementation program • Fertilizer = Facilitators • Pests = Barriers • Nursery = Repository of Tool kits • Extension agents = External Facilitators • Farmers = Quality managers

7. History of QUERI Program • Established in 1998 under Ken Kizer (USH) and Jack Feussner (CRADO) • Part of broader transformation of VA healthcare with focus on quality • Jointly supported by research and healthcare dollars • Stimulated by perception of “low hanging fruit” • E.g.,Only 50% of patients with CHF getting ACE inhibitors

8. QUERI Mission To improve the quality and value of Veteran’s healthcare by studying, testing, and implementing the most effective processes to ensure the timely and reliable adoption of new and established evidence-based treatments, tests, and models of care.

9. QUERI Funding Core support to 9 Centers and Resource Centers (dissemination, data, economics) Rapid response projects (1 year) Service-directed projects (3 years) Projects support: Center strategic plans Specific VHA Needs (e.g. PTSD assessment) Partnerships (e.g. nursing, rehab)

10. QUERI Centers QUERI Coordinating Centers PT/BRI-QUERI Minneapolis, MN SCI-QUERI Hines, IL DM-QUERI Ann Arbor, MI IHD-QUERI Seattle, WA CHF-QUERI Palo Alto, CA STROKE-QUERI Indianapolis, IN HIV/HEPATITIS C-QUERI Greater Los Angeles MH-QUERI Little Rock, AR SUD-QUERI Houston, TX

11. Criteria for a Successful QUERI Center • Contributes to measurable progress in a limited number of high-priority clinical issues within a content area • E.g. reducing re-hospitalization in CHF • Build effective partnership with clinical partner in order to improve use of research to improve programs and policies • Contributes to understanding of effectiveimplementation in VHA

12. QUERI’s Research/Implementation Pipeline Identify Research Area Implement Intervention & Document outcome Identify Best Practice Clinical Research / Guideline Development Implementation Research Implementation Policy, Improved Health Mainstream Health Services Research Assess Existing Practice Phase 1 Pilot Projects Phase 2 Small-Scale Demonstrations Phase 3 Regional Demonstrations Phase 4 “National Rollout”

13. What QUERI and IR Has to Offer • Clinical expertise • Deep understanding of data • Understanding of what is important • Understanding of health care context • Continuity with operational partners • Aligning elements of system for change • Guidelines, performance measures, policies • Work in more complex areas of care • “patient-centered care”, multiple morbidity • Work with more complex elements of change • Leadership, team functioning

14. Understanding Data

15. Knowing What’s Important

16. Where we sometimes struggle with change • Assumes linear process for change • Emphasis on “pushing” research findings to field rather than generating “pull” • Not enough emphasis on capacity and priorities of our health system partners • Haven’t aligned research incentives • Better at describing process than fixing it • Haven’t turned generalizable lessons from implementation research into actionable guidance for managers

17. Current realities in VHA and healthcare New implementation not driven by research Can’t rely on spending more to improve quality Change being driven by transformational priorities and performance measures Many new rollouts only minimally informed by research, little imbedded research

18. How do we generate “pull” in the system for our products? • Align research with the high-priority problems of the health system • Jump onto moving trains • “participatory action research”, PBRNs, etc. • Need to mix top-down and bottom-up efforts • centralized and locally driven approaches • Build capacity in field to support spread beyond the early adopters • Need “generalist” as well as “specialist” support

19. What Have We Learned From Implementation Science? • Multiple models to explain change process • No single model superior • Common factors: • Nature of change (simple or complex) • Importance and priority of change • Local context (microsystem) • External context • Target of change • Most changes require active facilitation • Local champions, tools, training • Barriers differ with specific sites • Leadership, resources, IT, inertia

20. Conclusions • Success of QUERI depends on long-term relationships between research and “customer” • Need to align with priorities at multiple levels • Generalizable lessons but no “magic bullets” • We can learn from SR about how to address system issues, reliability and efficiency • We can contribute in depth understanding of clinical effectiveness and impact, role of new models of care