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Quality Enhancement Research Initiative. Introduction to QUERI Implementation Research for VHA Operations Staff: What It is and Why It is Helpful Richard R. Owen, MD Director, Mental Health QUERI Jeffrey L. Smith, PhD(c) Implementation Research Coordinator, Mental Health QUERI April 28, 2009.

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Quality Enhancement Research Initiative

Introduction to QUERI Implementation Research for VHA Operations Staff: What It is and Why It is HelpfulRichard R. Owen, MDDirector, Mental Health QUERIJeffrey L. Smith, PhD(c)Implementation Research Coordinator, Mental Health QUERIApril 28, 2009

  • Clinical Research Translation Roadblocks and the Quality Chasm
  • Introduction to QUERI and Implementation Science
  • Examples of QUERI Projects
  • Barriers to and Opportunities for Greater Involvement of Policymakers and Managers
  • Discussion
the problem
The problem
  • Clinical researchtranslational roadblocks

Significant barriers impede timely progression of innovations from basic science to clinical application to routine use and population benefit

  • The healthcarequality chasm

Pervasive gaps exist in the quality, safety, equity, efficiency, timeliness and patient-centeredness of healthcare

translational roadblocks iom clinical research roundtable
Translational roadblocks:IoM Clinical Research Roundtable

Sung NS, Crowley WF et al., Central challenges facing the national clinical research enterprise, JAMA 2003.

implementation gaps and the quality chasm
Implementation gaps and the quality chasm

Most healthcare quality gaps result from insufficient implementation of evidence-based practices

Strategies and programs to accelerate implementation and to improve quality are similar and generally involve organizational and professional behavior change

possible solutions
Possible Solutions
  • “Push” research into practice – researchers get involved in implementation of research findings
  • “Pull” research into practice – policymakers, managers get involved in prioritization and planning of research
vha example
VHA Example









Prog Eval Centers

omhs policy initiative mireccs
OMHS Policy Initiative: MIRECCs









Prog Eval Centers

ord hsr d policy initiative queri



ORD/HSR&D Policy Initiative: QUERI










Prog Eval Centers


us department of veterans affairs quality enhancement research initiative queri
US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI)

QUERI MissionTo enhance the quality, outcomes and efficiency of VA health care by systematically implementing evidence-based clinical guidelines and innovations into routine clinical practice

nine queri coordinating centers
Chronic Heart Failure



Ischemic Heart Disease

Mental Health

Polytrauma/Blast-Related Injuries

Spinal Cord Injury


Substance Use Disorders

Nine QUERI coordinating centers
implementation research in health
“Implementation research in health”

Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services. It includes the study of influences on healthcare professional and organizational behavior.

-- Eccles and Mittman, Implementation Science 2006

implementation research policy practice goals
Implementation research policy/practice goals
  • Develop effective strategies for improving health-related processes and outcomes
  • Improve health-related processes and outcomes within participating study sites
  • Facilitate widespread adoption (or ‘spread’) of these strategies
implementation research science goals
Implementation research science goals
  • Generate new insights and generalizable knowledge regarding implementation processes, barriers, facilitators, strategies
  • Develop, test and refine implementation theories, hypotheses, models and principles
  • Develop improved approaches and methods for studying implementation
the classic six step queri process
Identify high risk/high burden conditions

Identify best practices

Define existing practice patterns in VA and variations from best practices

Identify (or develop) and implement programs to promote best practices

Document outcome and system improvements

Document improvements in health related quality of life

The Classic Six-Step QUERI Process
expanded queri six step process
Expanded QUERI Six-Step Process

Step 1: Select Diseases/Conditions/Patient Populations

1A. identify and prioritize high risk/high burden clinical conditions

1B. identify high priority outcomes and areas of practice within a selected condition

Step 2: Identify Evidence-Based Guidelines, Practices

2A. identify evidence-based clinical practice guidelines and recommendations

2B. identify evidence-based clinical practices, care models

Prioritize recommendations for implementation (based on gap, importance for outcomes, feasibility of improvement)

expanded queri six step process17
Expanded QUERI Six-Step Process

Step 3: Measure and Diagnose Quality/Performance Gaps

3A. measure existing practice patterns and outcomes and identify variations from evidence-based practices and benchmark outcomes (quality, outcome and performance gaps)

3B. identify determinants of current practices

3C. diagnose quality gaps

3D. identify barriers and facilitators to improvement

expanded queri six step process18
Expanded QUERI Six-Step Process

Step 4: Implement Improvement Programs

4A. identify implementation/quality improvement strategies, programs and program components or tools (e.g., via literature reviews, formative evaluation techniques)

4B. develop implementation/quality improvement strategies, programs, program components or tools

4C. implement quality improvement strategies and programs

Step 5/6: Evaluate Improvement Programs

5. assess improvement program feasibility, implementation and impacts on patient, family and system outcomes

6. assess improvement program impacts on health-related quality of life (HRQOL)


Implementing evidence-based depression treatment model in VA primary care(Example of Clinical-Research Partnerships at VISN- / National-Level)

depression care in va
Depression Care in VA
  • 7% of patients have depression diagnosis; 44% receive all or most treatment in primary care
  • Patients treated exclusively in primary care have fewer visits than those seen in mental health specialty care
  • Less than half (45%) of patients started on antidepressants receive adequate dose for guideline-recommended duration
collaborative care for depression
Collaborative Care for Depression
  • Integrated package of intervention tools / strategies, including…
      • Clinician education and decision support
      • Care management
      • Active collaboration between primary care and mental health specialists
      • Patient education and self-management support
  • Consistent with Chronic Care Model (Wagner)
collaborative care for depression22
Collaborative Care for Depression

Primary Care Clinician

Nurse Care Manager



collaborative care for depression23
Collaborative Care for Depression
  • Improves depression treatment, symptoms, functioning, work-related outcomes, quality-of-life, and is cost-effective
  • Achieving the Promise: Transforming Mental Health Care in VA –“Develop… a VA-adapted collaborative care model dissemination package as the basis for national rollout”
translating initiatives for depression into effective solutions tides
PI’s: Lisa Rubenstein, Ed Chaney

Implement collaborative care for depression in VAMCs from 3 VISNs (VISNs10, 16 & 23)

Use evidence-based quality improvement (EBQI) processes for tailored implementation


Patients kept 90% of follow-up appointments

Twice as many patients receiving collaborative care were treatment adherent

Depression symptoms significantly improved at 8-12 weeks

Improved work/social functioning at 6 months

Translating Initiatives for Depression into Effective Solutions (TIDES)
regional tides spread retides
PI’s: Rubenstein, Chaney

Sustainability in 1st generation TIDES sites (VISNs 10, 16, 23)

Spread collaborative care to new sites (VISN 22)

Evaluate impact of implementation on patient care, clinical outcomes, and costs

Build and leverage system support for further spread

Regional TIDES Spread (ReTIDES)
implementing and spreading collaborative care for depression
Implementing and Spreading Collaborative Care for Depression

Clinical / Research Partnerships

Leadership Support■Input on ‘TIDES National Dissemination Plan’■OMHS Primary Care / Mental Health Integration Initiative

Guidelines & Performance


■Updated depression guidelines (release pending internal VA review)■‘Guidance for Program Integrity’ developed, identifying key features of TIDES and related QI models (with performance targets)

Training & Education

■TIDES Depression Care Manager Manual■ TIDES resources accessible to all VA facilities via Sharepoint website■EES-sponsored TIDES trainings

Informatics Tools

■IT Expert Panel conference hosted by ReTIDES team resulted in plans to integrate TIDES software into VA ‘Mental Health Assistant’ tool



Adaptation to VA

Black Hills

Twin Ports

Sioux Falls


1st-generation sites(VISNs 10, 16, 23)




Care Model





Spreadto 2nd-generation sites

(VISNs 10, 16, 22, 23)





Efficacy / effectiveness studies (VA and other)


1st-generation sites


Improving metabolic side effect monitoring for veterans taking antipsychotic medications(Example of Clinical-Research Partnershipat VISN- / Facility-Level)

  • Psychotic disorders highly disabling and burdensome in VA
    • 1.3% prevalence of schizophrenia; over 90,000 vets treated annually
    • Vets w/ schizophrenia account for 12% of annual VA healthcare costs
  • Second-generation antipsychotics (SGAs) are a key component of treatment
    • Prescribed to over 80% of veterans with psychosis
  • SGAs can cause adverse metabolic side effects
    • Weight gain
    • Diabetes
    • Dyslipidemia
  • VA guidelines and ADA/APA consensus statement recommend monitoring and management of metabolic side effects for patients started on new antipsychotic
a study of strategies to improve schizophrenia treatment assist
A Study of Strategies to Improve Schizophrenia Treatment (ASSIST)
  • Objectives: Develop and test intervention strategies/tools to improve metabolic side effect monitoring for patients taking APs
      • Increase baseline monitoring for weight gain, diabetes onset, dyslipidemia
  • ASSIST Tools / Strategies
      • Educational tools (for clinicians and patients)
      • Clinical support tools
        • Pocket-sized booklet with AP side effect monitoring recommendations
        • CPRS clinical reminder for side effect monitoring
      • Performance monitoring tools
        • Monthly site-level performance reports
        • Weekly provider-specific feedback on side effect monitoring
      • Facilitated Team QI and Opinion Leader strategies
external facilitation in assist
External Facilitation in ASSIST
  • Facilitator
    • Maintained regular contact w/ local QI team
      • Email communication
      • Participate in monthly ASSIST Team meetings
    • Monitored implementation of project tools/strategies; performance on AP side effect monitoring and dosing
    • Identified and problem-solved barriers to implementation
    • Assisted in adapting tools/strategies as needed or suggested by local QI team to meet project goals
external facilitation products facility a
External Facilitation ‘Products’ (Facility A)
  • Collaborative research-clinical partnership
  • Placement of recommendations for antipsychotic side effect monitoring on medication order screens
  • Enhanced monthly performance reports, tailored to clinician preferences and specifications
  • Development of weekly reporting system identifying patients in need of metabolic side effect monitoring
    • Provider name, patient identifier, AP fill date, medication name, info on monitoring parameters
    • Now fully automated
ap side effect monitoring at facility a
AP Side Effect Monitoring at Facility A

Weekly reports implemented


barriers to clinical research partnerships
Barriers to “Clinical-Research Partnerships”
  • As part of the ReTIDES project, we interviewed 26 VHA leaders and key staff about perspectives on EBP implementation.
  • Barriers:
    • Research takes too long
    • Research isn’t practical
      • Researchers’ pursue their own career goals
      • Research tends to focus on single diseases
    • Managers have to balance available evidence with clinical needs
opportunities for enhanced collaboration and partnerships
Opportunities for Enhanced Collaboration and Partnerships
  • QUERI centers and other initiatives to bridge the gap, while being recognized for their impact, haven’t solved the problem
  • Clinical-research partnership should include early and active involvement of managers in research prioritization and design
  • Clinical-research partnership should include capacity for rapid research response to high priority needs of managers


Rick Owen (

Jeff Smith (

VA Mental Health QUERI