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QUERI Implementation Guide

Section II Part 1: VA QUERI Quality Improvement Demonstrations: Lessons Learned

• The activity of facilitation can create tension in a team of "traditional" health services researchers.

SCI: Tensions arose over which team members were to have contact with centers and what data was to be noted. This derived from a lack of shared understanding of qualitative and quantitative procedures. These issues can be reduced by regular team discussions about roles. Acknowledging the wide range of skills necessary for an implementation research project and broadening team knowledge about these skills can also help.

• Select measures carefully, look at differing sources of information (e.g., qualitative and quantitative), and look further if things don’t seem to add up.

SUD: At first it was believed that identifying the number of patients working on a detoxification goal would be a good indicator of the treatment orientation of a clinic; that is, the clinic is either oriented toward detoxification/abstinence vs. indefinite maintenance on methadone (the more desirable treatment orientation), or not. This was not necessarily the case because clinics universally reported that 90 to 100% of their patients were not currently working on a methadone taper goal. However, other indicators of a "detox" orientation, including lower-dose methadone and more punitive responses to continued substance use, were identified through policy reviews with clinic leadership. So, rather than using the proportion of patients with a maintenance goal as demonstration of clinic change, SUD used a more direct measure of program orientation, the Abstinence Orientation Scale³² as the measure for achievement of a maintenance orientation in the clinic.

• Be aware of benefits and problems of different staffing mechanisms and the impact of the immediate environment.

DM: One research staff person, who was part time on the project and who spent time in clinical areas, began spending more time on non-project activities than allocated, probably because of her ongoing relationships within the organization and being drawn into high priority activities taking place in the immediate environment. We were not aware of this until it had gone on for some time. This may have affected the outcome because the staff person had less time available for patient and provider contact and follow-up. However, spending some time on non-project activities builds a sense of participation and being part of the team. For another of our projects, one of the nurses was new to the organization. As research staff, she was hired and paid for by the project and was a temporary employee. Because she was not a known entity, she was an outsider, and her tenure was seen as temporary. This appeared to limit her ability to engage with the providers in working with them to suggest and make changes for the organization. On the other hand, another nurse who had worked at the institution and then took on the project tasks was already well known to the clinicians, and this was beneficial to the project functioning.

In yet another DM case management project, research project staff were treated differently (e.g., promotion opportunities) and negatively because they were temporary employees. At one DM site, project staff was perceived as being a group apart who did not attempt to "fit in" with the rest of the clinic staff. This then created tensions between the two groups – clinic staff and research staff.

• Evaluate time and cost burden.

HIV: We estimated that the average cost of implementing10 HIV-related clinical reminders per site was moderate at about $30,000 for the 12-month study period.

The average cost of implementing a group-based social support, Institute for Healthcare Improvement-style collaborative intervention per site was estimated – by site personnel – to be minimal at $6,000 for the 12-month study period. This intervention provided mentored application of a model for rapid quality improvement, adapted from the Institute for Healthcare Improvement’s Breakthrough Series, offered to two key HIV care providers from each of eight facilities.⁴³ See the Institute for Healthcare Improvement website for further information about breakthrough collaboratives.

*This section was collated and written by Mary Hogan, PhD, Implementation Research Coordinator (IRC) for DM QUERI and Hildi Hagedorn, PhD, IRC for SUD QUERI, with substantial input from other IRCs: Barbara Kimmel, PhD (CHF); Laura Kochevar, PhD (CRC); Candy Bowman, PhD (HIV); Anne Sales, PhD (IHD); Geoff Curran, PhD (MH); and Marcia Legro, PhD (SCI), and the Administrative Coordinator for CHF QUERI, Donna Espadas, MPH.