An organizational framework and strategic implementation for system-level change to enhance research-based practice: QUERI Series

Background The continuing gap between available evidence and current practice in health care reinforces the need for more effective solutions, in particular related to organizational context. Considerable advances have been made within the U.S. Veterans Health Administration (VA) in systematically implementing evidence into practice. These advances have been achieved through a system-level program focused on collaboration and partnerships among policy makers, clinicians, and researchers. The Quality Enhancement Research Initiative (QUERI) was created to generate research-driven initiatives that directly enhance health care quality within the VA and, simultaneously, contribute to the field of implementation science. This paradigm-shifting effort provided a natural laboratory for exploring organizational change processes. This article describes the underlying change framework and implementation strategy used to operationalize QUERI. Strategic approach to organizational change QUERI used an evidence-based organizational framework focused on three contextual elements: 1) cultural norms and values, in this case related to the role of health services researchers in evidence-based quality improvement; 2) capacity, in this case among researchers and key partners to engage in implementation research; 3) and supportive infrastructures to reinforce expectations for change and to sustain new behaviors as part of the norm. As part of a QUERI Series in Implementation Science, this article describes the framework's application in an innovative integration of health services research, policy, and clinical care delivery. Conclusion QUERI's experience and success provide a case study in organizational change. It demonstrates that progress requires a strategic, systems-based effort. QUERI's evidence-based initiative involved a deliberate cultural shift, requiring ongoing commitment in multiple forms and at multiple levels. VA's commitment to QUERI came in the form of visionary leadership, targeted allocation of resources, infrastructure refinements, innovative peer review and study methods, and direct involvement of key stakeholders. Stakeholders included both those providing and managing clinical care, as well as those producing relevant evidence within the health care system. The organizational framework and related implementation interventions used to achieve contextual change resulted in engaged investigators and enhanced uptake of research knowledge. QUERI's approach and progress provide working hypotheses for others pursuing similar system-wide efforts to routinely achieve evidence-based care.


Purpose
The Veterans Health Administration (VHA) Health Services Research and Development (HSR&D) invites applications for collaboration with Veterans Integrated Service Networks (VISN) on a) implementing and evaluating an evidenced-based intervention or b) undergoing and evaluating an organizational or structural change to transform the VISN into a learning organization 1 that can efficiently implement evidence-based practices. Collaborations are intended to help improve clinical services locally within participating VISNs and provide templates for expanding successful changes nationwide.

Background
VHA needs to develop efficient ways to broadly implement evidence-based practices and foster a learning organization culture that systematically and continuously applies research to improve VA healthcare. Continuous quality improvement (CQI) methods strive to evaluate and improve quality as an ongoing organizational process, but have usually not included an evidence-based intervention focus. Organizational research points to the importance of leadership, teamwork, cultural openness to innovation, and flexible management structures and styles. It also emphasizes integration of quality feedback and data as important organizational characteristics that can improve quality. While these characteristics might help support evidence-based quality improvement, well-defined methods for producing such cultures in clinical organizations do not exist.

Objectives for Projects
This solicitation requires a collaborating partnership of VISNs and health services researchers to accomplish two goals: A) Facilitate implementation of evidence-based practices. This facilitation could occur in two ways. First, a VISN could directly implement evidence-based practices. These evidencebased practices should improve care delivery for important clinical areas (e.g. high cost, high prevalence, high need, vulnerable populations). Alternatively, the VISN could undertake organizational or infrastructure development efforts that support evidence based practice implementation (e.g. development of training programs, researching new quality improvement organizational structures).
B) Generate knowledge that will facilitate implementation of evidence-based practices nationally. Each applicant team will be responsible for ensuring that progress or findings in its network can be generalized and transformed into useful guidance for other VISNs. This goal will be accomplished by activities that test or develop theories about implementation, and a dissemination plan that ensures the general lessons about implementation, and the specific lessons of implementing individual evidence-based practices, are effectively communicated to other VISNs.

Eligibility
The application should originate jointly from a VISN Director or senior Network-Officer (e.g. a Network Clinical Manager) and a collaborating VA researcher. Multiple VISN directors can also collaborate with a single researcher to submit a unified application for multi-network projects. The VISN leader and the researcher should be CO-Principal Investigators, with either listed as "lead".

Finding Collaborators
The new Office of Research and Development Implementation Unit within HSR&D will assist researchers and networks in identifying potential collaborators. Interested researchers without partners should submit an Implementation Topic one page summary. Please prepare the one page summary, in 12 point font, addressing the following areas: 1. PI Contact information (Name, Phone, Email, address) 2.
Purpose/Goals of proposed program 4.
Brief description: How this study will facilitate implementation of evidence-based practices and/or generate knowledge that will facilitate implementation of evidencebased practices nationally.

5.
Special population or facility needs (if any) from a partner VISN (e.g. a high volume of patients that have a history of homelessness, rural hospitals, a spinal cord injury treatment center, etc.) One-pagers may be submitted at any time. However, to facilitate partnering in time for the first application, please submit electronically your one-pager by

Evaluation Criteria
Proposals will be evaluated based on the extent to which they: 1) are innovative, but draw from the theoretical and empirical evidence base on organizational change and healthcare provider behavior; 2) have sound organizational structure; 3) involve key stakeholders in planning and execution; 4) show promise for enduring and expanding success throughout VHA; 5) rapidly create clinical and organizational improvement; 6) exhibit budget efficiency and network commitment, and 7) will add to the general scientific and practical understanding of implementation.
Because of the complexity of this process, funding will proceed in two phases.

6a. Phase 1: Planning Proposals
HSR&D will award up to $50,000 per planning application to fund up to six months of planning and application writing activities. These six months will allow applicants the necessary time to develop a sound research and dissemination plan, identify a clinical or organizational intervention, and generate support from all key stakeholders. These funds will support all aspects of planning and proposal writing (e.g. salary, travel, pilot data).
The planning award application should describe, in no more than two pages of 12 point font text, preliminary plans for addressing Objectives A and B above, involvement of researchers and key stakeholders, and the process to develop a final proposal. In addition, a budget and biosketches for Co-PIs should be included on VA forms 1313-2 to 1313-6. The planning award application also must contain a one page letter of support signed by the VISN director(s) and one additional page for optimal timeline, if desired.
Proposals will undergo peer review by an ad hoc committee, selected from members of the HSR&D Scientific Review and Evaluation Board, Network representatives and VHA Headquarters staff. Proposals will be evaluated on the basis of their scientific merit and expected contribution to improving VA health services. Proposals recommended for approval will then be considered for funding.
Planning award applications will be due October 15 and April 15 of every year, with funding correspondingly announced by December 15 and June 15. Note: for FY2004 only the submission deadlines will be November 15, 2003 and April 15, 2004. Funding will be announced by December 15, 2003 andJune 15, 2004. HSR&D expects to fund 15-20 planning awards in FY04 and anticipates that about 50% of the planning awards will result in fully funded proposals.

6b. Phase 2: Final Proposals
Successful planning awards are expected to result in submission of a Phase 2, Final Proposal. The final proposal must follow the standard format and requirements for an HSR&D merit review application (for instructions, see www.hsrd.research.va.gov/for_researchers/funding/application/guidelines/ch3.cfm). However,