FORUM translating research 

into quality health care 

for veterans

A publication of the VA Office of Research 

& Development, Health Services Research 

& Development Service, Center for 

Information Dissemination and Education 

Resources, in conjunction with AcademyHealth 

August 2006 

Contents 

Director’s Letter 2

Response to Commentary 3

Research Highlights 4

Overview of PT/BRI QUERI 6

Implementation Science 7

VA Health Services Research & Development Service 

QUERI II: The Next Generation 

By Joseph Francis, M.D., M.P.H., Acting Deputy Chief Research and Development Officer, and 

Associate Director, HSR&D QUERI 

With eight years of experience, the Quality ■ Decreased readmission for patients with 

Enhancement Research Initiative (QUERI) is chronic heart failure. 

not only looking back and taking stock but also 

moving forward in new directions. From its QUERI groups are evolving to meet the chang

beginning in 1998, QUERI emphasized the ing needs of veterans. Recent projects have 

implementation of evidence-based research focused on patient self-management, one 

into improvements in routine care. Today there example being peer counseling for diabetic se

are 10 QUERI Centers that focus on a disease or care. QUERI groups are also collaborating wit

condition, including colorectal cancer, diabetes, important VA operational offices that are 

heart disease, HIV/AIDS, mental health, sub­ championing the use of technologies, includstance use disorders, spinal cord injury, stroke, ing implementation of personal health record

and polytrauma and blast-related injuries. (MyHealtheVet) and distance technologies for 

These groups have developed and tested inter­ coordinating care in home and community se

ventions resulting in significant improvements tings. Other projects include evaluating the us

in the quality of care received by veterans. of electronic evidence-based recommendation

and the routine feedback of patient-reported 

health status to providers.2 

Successes and Lessons Learned 

While QUERI has achieved remarkable success The VA initiated QUERI as an “output-oriented approach to quality improvement.”1 in eight short years, challenges experienced by True to 

the Centers offer important lessons as QUERI this promise, many QUERI projects have enters its next phase. Chief among these lesson

developed interventions resulting in dramatic is the need to increase collaboration and inter

improvements in quality of care, including action between researchers and other areas of doubling the flu vaccination rates among the VA that are devoted to quality improvemen

spinal-cord injured veterans. QUERI projects This will ensure the uptake of findings into have facilitated the spread of collaborative care practice. One obstacle to overcome in this for depression in VA’s primary care settings regard is the difficulty in funding collaborative and improved adherence to antidepressant efforts through existing grants and budgets. medication. Other successes include: 

■ Decreased use of inappropriately high 

doses of oral antipsychotic drugs for schizo­ Looking Ahead to a New Generation of 

phrenia and a corresponding decrease in costs; QUERI 

■ Improved adherence to guideline-based VA is now turning its attention to creating a treatment of HIV; leaner and faster QUERI framework with an 

■ Increased use of opioid agonist therapy emphasis on collaboration and pilot studies 

among patients with narcotic addiction; and, continued on page 
2 ■ Forum/August 2006 

that will yield “fast track” results. The new 

generation of QUERI will focus broadly, 

and not just restrict new activities to single 

diseases or conditions. One aspect that will 

remain unchanged, however, is QUERI’s 

focus on studying and implementing 

research that targets high-priority health 

care problems faced by veterans. 

The goals of the next generation of QUERI 

are to: 

■ Create a strong partnership between 

researchers and facility leaders; 

■ Seek evidence-based interventions for a 

broader range of conditions affecting veterans; 

■ Identify opportunities for VA researchers 

to collaborate in national initiatives; and, 

■ Assess on an ongoing basis the research 

pipeline and its relation to the care and 

needs of veterans. 

These goals will demand a new activist role 

for QUERI—and for HSR&D—as facilitators 

and partners in systems transformation. 

The emphasis will be on faster and more 

responsive research and implementation. 

QUERI should aim not to shoulder the burden of large national implementation but to 

test “hands-on” implementation with smallscale pilots and medium-sized projects. 

With a tight budget, QUERI will need to 

start small and act fast, with a focus on sustainable, optimal interventions, and further 

use of partnerships within VA to scale these 

up to a national level. 

VA’s newest QUERI Center reflects these 

goals. The Polytrauma and Blast-Related 

Injuries QUERI addresses the needs of 

young veterans returning from Iraq and 

Afghanistan who have survived blast 

injuries. These men and women have sustained multiple and traumatic injuries— 

including brain injury, amputation, and 

mental illness—that require complex care.3 

As a result, the Polytrauma and BlastRelated Injuries Center reflects an interdisciplinary and co-morbidity oriented 

approach that is a hallmark of the new 

QUERI. The VA’s next QUERI Center will 

address home- and community-based long 

term care and managing the needs of veterans with multiple chronic illnesses. 

Innovations in technology have been a cen

tral component of QUERI. The new generation of QUERI projects will enhance the 

VA’s ability to use the Electronic Medical 

Record (EMR) for systems learning. The 

EMR has enabled VA to improve care man

agement for diabetes patients by collecting 

information regarding prevalence, comorbidities, and costs into a diabetes database 

(DEpiC). The EMR of the future will becom

a patient health record that the patient owns 

and controls, as well as a platform for continuous learning by system clinical leaders 

in partnership with VA researchers. 

As QUERI moves in these new directions, 

VA is also committed to using the latest 

technology to develop the capacity and skil

sets of its investigators. HSR&D’s new 

Cyber Seminars program reflects this com

mitment (see related article page 7). 

While QUERI has achieved remarkable 

success since its inception, it is time to 

build on these early accomplishments with 

the goal of continually improving the care 

received by veterans. Ultimately, the new 

generation of QUERI will create a learning 

system where clinical care, data, and 

research are interlinked and VA is recognized as a premier health system for gener

ating and applying knowledge to improve 

the health of veterans and the nation. ■ 

References 

1 Francis J, Perlin J. Improving performance through knowledge translation in 

the Veterans Health Administration, The 

Journal of Continuing Education in the 

Health Professions 2006, 26(1):67. 

2 QUERI Quarterly, Vol. 7, No. 1, March 

2005, p. 1. 

3 Francis and Perlin, p. 68. 

Director’s Letter 

While many FORUM readers may have 

experience with the work of at least one 

QUERI group, consensus at our last FORUM 

Editorial Board meeting was that many 

readers may not have a comprehensive 

understanding of the overarching QUERI 

goals and accomplishments to date. Thus, 

this special FORUM supplement focuses 

on QUERI. First, Dr. Francis ably summarizes 

QUERI’s foundation, the current state, and 

where it is headed. Dr. Ordin then provides 

an important operational viewpoint on 

QUERI efforts. Partnerships between 

operations and research are critical to the 

success of QUERI. Two QUERI research 

efforts are highlighted and the newest 

QUERI, the Polytrauma and Blast-Related 

Injuries QUERI, is profiled. 

In other news, we are pleased and proud 

of the strong presence VA HSR&D made 

at the recent Society of General Internal 

Medicine (SGIM) and AcademyHealth 

Research Meetings. At SGIM in Los 

Angeles last April there was a special VA 

symposium on implementation of evidencebased care models as well as VA participation in numerous other sessions on topics 

such as health disparities and caring for 

veterans returning from Iraq. At the 

AcademyHealth Meeting held in Seattle 

last June, a special VA session highlighted 

the impact of global conflicts on the VA 

Health Care System, as well as other sessions on managing chronic disease and 

lessons from implementation of the electronic health record. In addition, nearly 50 

VA researchers were presenters or moderators of sessions and an additional 71 

HSR&D researchers had poster presentations. This visibility is evidence of the high 

quality and timely research that is conducted by our many talented HSR&D 

investigators. 

Mark your calendars! HSR&D’s National 

Meeting is scheduled for February 21-23, 

2007. See www.hsrd.research.va.gov/ 

about/national_meeting/2007 for details. 

Shirley Meehan, M.B.A., Ph.D. 

Acting Director, HSR&D 
Forum/August 2006 ■ 

Response to Commentary
 

QUERI II and VA Performance Improvement 

By Diana Ordin, M.D., M.P.H., Director, Quality Improvement, Office of Quality and 

Performance 

Performance measures are important drivers—perhaps the most important drivers— 

of systematic quality improvement efforts 

within VA. Performance measures are 

selected based on their importance in 

improving and maintaining veterans’ health, 

and in improving VA efficiency and effectiveness. At the operational level, performance measures delineate performance 

improvement priorities, and VISN and 

medical center leadership are held accountable for performance measure results. 

The VA has attained remarkable levels of 

quality of care in areas addressed by performance measures. Asch et al, reported 

that VA patients received higher quality care 

compared with non-VA patients over a broad 

spectrum of clinical areas, noting that the 

VA advantage was most prominent in processes targeted by performance measures.1 

Numerous examples (e.g., surgical infection 

prevention measures, pneumonia measures) 

of supporting indicators improving only after 

becoming performance measures, provide 

further evidence that performance measures 

are effective in driving improvement. See 

performance measures section of 

vaww.oqp.med.va.gov/. 

Opportunity for Further Improvement 

Despite the demonstrated ability of VA to 

improve (and sustain improvement) on 

performance measures, there is considerable opportunity to increase both the 

extent and pace of improvement. For many 

performance measures, even some with 

high overall VA performance, there is variation in performance across medical centers, as well as variation in improvement 

rates once improvement begins. For many 

performance measures, evidence-based 

improvement strategies have been neither 

described in the literature nor systematically identified and disseminated within VA in 

a manner meeting the improvement imperatives of VISNs and medical centers. 

The first-generation QUERI produced many 

high-quality studies. However, the disconnect between QUERI research and the 

operational components of VA, and differing expectations of researchers and on-theground improvers of care, meant that much 

of QUERI’s output failed to address the 

most pressing needs of VA care providers 

in a timely manner. 

The second generation of QUERI, as 

described in Dr. Francis’s article, is designed 

to address these issues. The new “leaner 

and faster” QUERIs, with “increase(d) collaboration and interaction between researchers 

and other areas of the VA” and addressing a 

broader range of clinical issues, are likely 

better able to assist the VA system’s most 

urgent improvement priorities, including 

those embodied in performance measures. 

Quality Improvement Technical 

Assistance Projects 

Current collaborative efforts between QUERI 

and other ORD researchers, Program Offices, 

and regional and medical center staff illustrate QUERI II’s potential contribution to 

rapid improvement on performance measures. With funding primarily from the 

Office of Quality and Performance, these 

Quality Improvement Technical Assistance 

Projects (QI TAPs) use literature reviews, 

analysis of VA performance measures data, 

and interviews with high, low, and rapidlyimproving performers to identify, package, 

and disseminate readily-usable information 

on “effective” care processes for selected 

performance measures. Technical Advisory 

Teams, consisting of clinical content expert

and field quality improvement and clinical 

staff who are involved in the relevant processe

of care, inform project design and product. 

Perfor-mance measures selected for these 

projects are those with the greatest systemwide potential for improvement across mul

tiple medical centers—and for which there 

is some evidence, either inside or outside 

the VA, that high performance is achievable

Current QI TAPs address a range of performance measures, including: 

■ prevention of surgical site infection, 

■ timely administration and appropriate 

selection of antibiotics for communityacquired pneumonia, 

■ emergency room processes of care for 

acute coronary syndromes, 

■ missed appointment opportunities, 

■ consult completion rates, 

■ delays in lung cancer diagnosis and 

treatment, and 

■ timeliness and reliability of colorectal 

cancer diagnosis and treatment. 

The key challenge for researchers engaged 

in these projects is developing methods for 

identifying “effective” processes of care 

using what is essentially a set of anecdotes. 

We hope that these and future collaborations will enable QUERI II and other ORD 

researchers to pioneer development of 

“rapid-cycle” methods for identifying evidence-based improvement strategies— 

methods that will meet the urgent needs of 

VA leaders and care providers. ■ 

References 

1 Asch SM, McGlynn EA, Hogan MM, et al

Comparison of quality of care for patients i

the Veterans Health Administration and 

patients in a national sample. Annals of 

Internal Medicine 2004; 141:938-45. 
4 ■ Forum/August 2006 

Research Highlights
 

Measuring Quality of Care for VA Patients Who 

Misuse Alcohol 

By Katharine Bradley, M.D., M.P.H., Daniel Kivlahan, Ph.D., Emily Williams, M.P.H., Eric 

Hawkins, Ph.D., and Carol Achtmeyer, M.N., Northwest HSR&D Center of Excellence for 

Outcomes Research in Older Adults, and Center of Excellence in Substance Abuse Treatment 

and Education, (CESATE), VA Puget Sound University of Washington 

Almost a quarter of VA patients misuse 

alcohol, meaning they drink at levels associated with adverse health outcomes or meet 

diagnostic criteria for alcohol abuse or 

dependence (AUDs). Randomized controlled 

trials and multiple meta-analyses have 

demonstrated that offering brief counseling 

to patients who misuse alcohol results in 

decreased drinking. Moreover, based on the 

magnitude of health benefits and cost effectiveness, a National Commission recently 

ranked brief alcohol counseling among the 

top 10 U.S. prevention priorities. However, 

this evidence-based practice has not been 

widely implemented. Over the past five 

years, the Substance Use Disorders (SUD) 

QUERI has developed practical measures to 

identify and risk-stratify patients with 

symptoms of alcohol misuse, to monitor 

brief alcohol counseling, and to evaluate 

outcomes, as the first step towards implementing brief alcohol counseling in VA. 

Despite widespread alcohol screening, the 

VA lacked a standard method for identifying 

patients who misused alcohol until 2004. 

Prior to this, most VAs used the CAGE 

questionnaire. This questionnaire, however, 

only screens for alcohol use disorders and, 

in fact, many CAGE-positive patients no 

longer drink alcohol. SUD QUERI investigators determined that the three-item 

AUDIT-C performed as well as longer 

screening tests and much better than the 

CAGE as a brief screen for alcohol misuse 

when compared to standardized interviews. 

In 2004, annual screening for alcohol misuse became a VA performance measure. 

Since adopting this measure, rates of 

screening have been high (93 percent of 

patients screened), with most sites using 

the AUDIT-C questionnaire. Following 

implementation of the screening measure, 

SUD QUERI investigators wondered whether 

alcohol screening in clinical practice identified alcohol misuse as effectively as screening 

in studies where questions were asked verbatim, in a nonjudgmental manner, and in 

private settings. Analyses of a national sample of VA outpatients found that the prevalence of positive AUDIT-C’s documented in 

medical records in 2004 was significantly 

lower than when the same patients completed the AUDIT-C on the VA Survey of 

Healthcare Experiences of Patients (SHEP). 

As a result, the SUD QUERI is collaborating with the VA Office of Mental Health 

Service and Office of Quality and 

Performance to standardize screening with 

a modified performance measure. 

Is the AUDIT-C Overly Sensitive? 

The VA ACQUIP trial tested a paper-based 

audit and feedback intervention and 

showed no effect on patient reports of alco

hol-related advice or drinking outcomes. 

Moreover, audio-taped appointments of 

patients who screened positive for alcohol 

misuse at one ACQUIP site showed that, 

despite provider education, alcohol-related 

discussions were rare, typically awkward, 

and omitted important components of evidence-based brief alcohol counseling. 

We have also compared mailed SHEP 

surveys and External Peer Review Process 

(EPRP) chart reviews for measuring 

provider follow-up on positive alcohol misuse screens. EPRP monitors follow-up 

assessment of patients who screen positive 

for alcohol misuse, but was not designed 

to monitor care in subgroups of patients 

(e.g. those with alcohol misuse) so the 

number of patients with alcohol misuse 

monitored quarterly per VA Network is 

currently too small for precise performance 

monitoring. Although the SHEP survey 

includes the AUDIT-C and asks whether 

patients have been advised by their VA 

provider to cut down or stop drinking, 

patients may not accurately recall or report 

alcohol-related advice. 

continued on page 

Providers administering the AUDIT-C note that patients who report drinking within recommended limits—one or two drinks daily—can score positive on the AUDIT-C (four points). How can 

that be? This occurs because the AUDIT-C score is an effective screening test when used as a 

scale, but the amount a patient reports drinking on questions one and two of the AUDIT-C is 

often an underestimate of patients’ reports of their drinking when they are interviewed with 

more detailed standardized interviews, which are the “gold standard” for alcohol-related 

research. We therefore encourage clinicians to think of the AUDIT-C as a scale like HA1C or 

blood pressure. Second, a significant minority of VA patients with AUDIT-C scores of four to five 

have previously received treatment for a drinking problem and 46 percent of these patients 

report problems due to drinking in the past year (compared to 25 percent of other VA patients 

with AUDIT-C scores of four to five). 
Forum/August 2006 ■ 

Telehealth Applications for Veterans with Stroke 

By Neale R. Chumbler, Ph.D., Rehabilitation Outcomes Research Center & Stroke QUERI, 

North Florida/South Georgia Veterans Health System, and Helen Hoenig, M.D., M.P.H., 

Physical Medicine & Rehabilitation Service, Durham VA Medical Center 

Stroke is one of the most disabling and 

costly impairments. According to the VA 

Stroke QUERI, approximately 15,000 veterans are hospitalized for stroke annually with 

new strokes costing an estimated $111 million for acute inpatient care, $75 million for 

post-acute inpatient care, and $88 million for 

follow-up care in the first six months following a stroke. Rigorous and coordinated 

inpatient care can improve the health status 

of patients who have suffered from a stroke. 

Barriers to Care 

There is increasing attention in implementing mechanisms and programs to reduce 

hospital lengths of stay for stroke patients. 

Early discharge rehabilitation programs 

need coordinated, efficient, in-home rehabilitation; inadequate information about the 

home setting hinders successful rehabilitation. Regrettably, resources for home-based 

rehabilitation are limited.1 Consequently, 

many veterans must travel considerable distances from their place of residence to the 

nearest VA hospital, limiting evaluation of 

the home.2 The Stroke QUERI previously 

found that a large number of acute stroke 

patients live more than 120 minutes from 

an inpatient rehabilitation unit (RBU). 

More than three out of four veterans who 

experience an acute stroke receive care 

from hospitals that do not have a RBU.2 

This finding suggests that barriers to 

accessing post-acute stroke rehabilitation 

exist for many veterans. These veterans 

need a practical, easily accessible, and 

potentially cost-effective model of community-based stroke rehabilitation.1 

Telehealth technologies (delivery of health 

care services at a distance) offer the potential to extend post-acute stroke care into the 

home-setting (“tele-rehabilitation” or TR). 

TR provides distance support, assessment, 

and intervention to people with disabilities 

through telehealth technologies.1 Despite its 

potential, there have been few TR applications 

in stroke. New telehealth methods are needed to manage stroke patients without compromising VA’s standards of high quality care. 

As a result, there is increasing recognition 

among health care providers that in-home 

therapy is a viable rehabilitation strategy to 

improve independence, safety, and quality 

of life among older adults with disabilities. 

By expanding rehabilitation beyond the hospital, TR could address the barriers experienced by veterans accessing post acute 

stroke rehabilitation in several ways. First, 

TR could be used to consult with providers 

who treated the veteran in the hospital, 

improving coordination of care. Second, TR 

could be used for cost-effective follow-up 

after a therapy home visit. Finally, home 

health nurses might use TR to provide 

physical and occupational therapists with 

crucial information prior to a home visit, 

increasing efficiency. 

New Telehealth Approaches 

Chumbler, Hoenig and their colleagues will 

soon examine a TR intervention that 

employs telehealth technology to improve 

rehabilitation outcomes of stroke patients 

after discharge in the home. The primary 

aim of the study is to determine the effect 

of TR on physical function. This Phase II, 

four-site, two-arm randomized clinical trial 

aims to improve functional mobility via two 

types of telehealth technology. Televideo is 

used to conduct in-home assessments of 

functional mobility, to make treatment recommendations, and to provide periodic 

goal-oriented reassessment, modifying the 

treatment plan as the patient improves. 

Televideo uses a mobile, wireless video 

technology with a home health aid in the 

patient’s home to provide live visual and 

audio communication between the patient 

and the home health aid in the patient’s 

home, and a therapist located at the base 

hospital. The second type of telehealth tech

nology is an interactive, in-home messagin

device that will be used to facilitate adherence with treatment recommendations and 

to screen for interval problems (depression

falls, and difficulty with self-care). 

TR has potential applicability to other veteran 

populations needing rehabilitation, including veterans with poly-trauma and spinal 

cord injury. As more telehealth studies are 

implemented for older veterans with mobil

ity disability, such as stroke, results could 

support the creation of national partnership

to implement more effective approaches to 

coordination of care when transitioning 

from hospital to home. ■ 

References 

1 Lai JCK, Woo J, Hui E, Chan WM. 

Telerehabilitation—a new model for community-based stroke rehabilitation. Journal 

of Telemedicine and Telecare 2004; 10:199­

205. 

2 Hoenig H, Sloane R, Horner RD, et al. 

Differences in rehabilitation services and 

outcomes among stroke patients cared for 

in veterans hospitals. Health Services 

Research 2001; 35(6):1293-1318. 
6 ■ Forum/August 2006 

Overview
 

The Polytrauma and Blast-Related Injuries 

QUERI: Evidence-Based Rehabilitation for the 

New Generation of War Injured 

Nina A. Sayer, Ph.D., L.P., Center for Chronic Disease Outcomes Research, Minneapolis 

VA Medical Center 

Modern warfare is resulting in new and Service funded the Polytrauma and Blastmplex patterns of blast-related injuries. Related Injuries (PT/BRI) QUERI. The 

he severity and pattern of blast injuries PT/BRI QUERI is partnering closely with 

pends on the explosive composition and the Polytrauma Rehabilitation Centers to 

ount of material involved, surrounding fulfill its mission and goals. 

vironment, delivery method, distance 

tween the victim and the blast, and pres­ The mission of the PT/BRI QUERI is to 

ce of intervening protective barriers or promote the successful rehabilitation, psyvironmental hazards. Blast-related injuries chological adjustment, and community ree often “polytraumatic,” meaning that they integration of individuals who have experisult in impairments in more than one body enced polytrauma and blast-related injuries. 

stem or organ at the same time. Due to The scope of the PT/BRI QUERI research 

provements in body armor, as well as in portfolio includes the range of health probttle site and acute trauma care, more severely lems, and health care system and psychosojured service members are now surviving cial factors that affect veterans with polyyond the acute phase of blast injuries.1,2,3 trauma and blast-related injuries. High prihe severity of their injuries results in sig­ ority goals include development of data sysificant impairments and adjustment chal­ tems for tracking injured service members 

nges for injured soldiers and their families. and monitoring rehabilitation outcomes; 

optimizing care coordination and continuity 

of care; ensuring screening for “invisible” 

omplex Rehabilitation Needs co-morbidities among blast-exposed individuals; and reducing caregiver burden. 

dividuals with polytraumatic and blastlated injuries have complex rehabilitation PT/BRI QUERI is undertaking a needs 

eeds. New structures and processes of care assessment through two related HSR&D 

e needed to maximize their functional funded Rapid Response Projects. The first 

d psychosocial outcomes. Recognizing is a qualitative study which involves interis, Congress authorized and the Secretary views with a select group of providers from 

 Veterans Affairs designated four each of the four Polytrauma Rehabilitation 

olytrauma Rehabilitation Centers located Centers. The second involves chart review 

 Minneapolis, Minn., Palo Alto, Calif., and VA administrative data extraction for all 

ichmond, Va., and Tampa, Fla. These combat injured service members from the 

olytrauma Rehabilitation Centers provide wars in Iraq and Afghanistan who received 

ecialized inpatient rehabilitation treatment inpatient rehabilitation at one of the four 

d have expanded expertise in this impor­ Polytrauma Rehabilitation Centers. 

nt clinical area throughout VA. To promote Together, these studies will help identify 

idence-based practice within the care gaps and needs, barriers and facilitators of 

ructures being developed for new veterans best practices, and sources of variation in 

ith severe combat injuries, VA HSR&D outcomes across the Polytrauma 

d Rehabilitation Research & Development Rehabilitation Centers. 

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Broad Scope Offers Challenges 

The PT/BRI QUERI faces unique challenges

First, our scope is broad, spanning the con

tinuum of care from the DoD to the VA to 

community-based facilities and including 

multiple morbidities. A more narrow scope 

would fail to address the complex reality of 

individuals with polytraumatic battlefield 

injuries. Within this broad scope, however, 

we are prioritizing traumatic brain injury 

(TBI), which presents in the context of other 

combat-related injuries (TBI with polytrauma

We selected this as our primary focus because 

of the prevalence of blast-related TBI with 

polytrauma in new veterans. Traumatic ampu

tation is our second priority clinical area. 

A second challenge is that evidence-based 

practices for individuals with polytraumatic 

and blast-related injuries are less welldefined than for other QUERI conditions. 

While significant, this challenge is not 

uncommon in medicine. To meet this chal

lenge, the PT/BRI QUERI is drawing from 

related fields of medicine, promoting 

research to expand the evidence base for 

practice, and using the “best available” 

evidence, including expert consensus. 

Ultimately, the PT/BRI QUERI aims to pro

mote evidence-based rehabilitation for the 

new generation of war-injured as well as 

advance the science of implementation. ■ 

References 

1 Scott SG, Vanderploeg RD, Belanger HG, 

et al. Blast injuries: Evaluating and treating 

the postacute sequelae. Federal Practitioner 

2005; Jan:67-75. 

2 Peake JB. Beyond the purple heart— 

continuity of care for the wounded in Iraq. 

New England Journal of Medicine 2005; 

352(3):219-22. 

3 Okie S. Traumatic brain injury in the war 

zone. New England Journal of Medicine 

2005; 352(20):2043-47. 
Forum/August 2006 ■ 

Implementation Science to Publish QUERI Issue
 

This fall, BioMed Central’s new journal 

Implementation Science will publish a special 

issue devoted to VA’s QUERI—a quality 

improvement program designed to facilitate 

the implementation of research findings 

into routine clinical practice. This issue will 

describe the evolution of the QUERI program and its contributions to the field of 

implementation science. 

A New Field 

Implementation science is a new field in 

which standard frameworks, tools, and even 

definitions are yet to be developed. QUERI 

was created eight years ago as a groundbreaking initiative and its investigators have 

much to share that may provide insight into 

this exciting new field, including valuable 

lessons learned. Articles in this special 

issue will provide an overview of the 

Veterans Health Administration (VHA) and 

the QUERI program, and will discuss 

QUERI models and tools, organizational 

factors that support or impede implementation interventions, and case studies. The 

issue also will include commentaries by 

both VA and non-VA collaborators who 

offer their perspectives on QUERI. 

The issue presents the QUERI process and 

implementation research framework, and 

emphasizes the need to measure strategies 

and impacts over time. Sustaining impacts 

is a critical focus for QUERI, and marketing is an important component of sustainability. One article describes the marketing 

effort behind the national rollout of a collaborative care intervention for depression 

treatment in primary care settings, while 

other articles discuss regional implementation strategies. For example, a QUERI case 

study describes how the QUERI process 

was used to determine whether undiagnosed HIV infection is high-risk and/or 

high-volume among veterans seen in a 

group of VA clinics. Based on an initial 

assessment, QUERI then developed and 

initiated a pilot project aimed at improving 

rates of HIV testing in one VA network. 

Additional case studies highlight lessons 

learned from a series of projects aimed at 

improving eye care for veterans with diabetes, and the application of implementation research methods to improve care for 

veterans with schizophrenia. 

Organizational Factors Play Role 

The upcoming QUERI-themed issue of 

Implementation Science also focuses on organizational factors surrounding implementation research, such as building and leveraging system support, strategies and tools for 

partnering with VA’s Internal Review 

Boards (IRBs), and the influence of organizational characteristics on implementation 

research. The issue will help those interested in implementation science to understand the strategies, processes, and factors 

that assist or hinder implementing evidence-based interventions aimed at improv

ing the health and health care of our 

nation’s veterans. 

Implementation Science is an open access, 

peer-reviewed online journal that publishes 

research relevant to the scientific study of 

methods to promote the uptake of research 

findings into routine healthcare in both 

clinical and policy contexts. For more information about the journal, visit www.implementationscience.com; also see the HSR&D 

web site at www.hsrd.research.va.gov for an 

upcoming announcement about the publication of the QUERI-theme issue. ■ 

HSR&D Cyber Seminars Program Features QUERI Sessions 

VA’s Health Services Research and Development Service (HSR&D) Cyber Seminars program is 

hosting a series of sessions about implementation science and research featuring presenters 

from VA’s QUERI. QUERI research examines methods to accelerate the implementation of evidence-based clinical practices in routine health care settings. During the cyber seminar sessions, 

QUERI investigators will share information about their implementation processes, methods, 

and lessons learned. The first series of sessions targets the role, value, and application of formative evaluation as it pertains to implementation research. This series of seminars also will 

describe the importance and role of four stages of formative evaluation in gaining a better 

understanding of how to implement research evidence into clinical practice to improve the quality of health care. 

Those who may benefit from participating in these sessions include clinicians, researchers, 

administrators, and policymakers interested in learning more about implementation science and 

the tools needed to promote evidence-based medicine. Recorded versions of the recently completed QUERI sessions are available for on-demand viewing. Additional sessions in the QUERI 

series will be scheduled for Fall 2006. Also relevant to this audience are the cyber seminars 

offered by HSR&D’s Resource Centers on topics such as the economic evaluation of VA data, 

clinical informatics, and measurement methods and techniques. 

To register for upcoming sessions, access archived sessions, or learn more about the Cyber 

Seminars program, please visit www.hsrd.research.va.gov/for_researchers/cyber_seminars/. 
Bradley continued from page 4 

Therefore, as a means for both prompting 

and guiding primary care brief alcohol 

counseling and capturing documented 

counseling electronically for performance 

monitoring, we are developing and evaluating 

electronic clinical reminders for brief alcohol 

counseling in the VA Computerized Patient 

Record System. Based on testing in two VA 

Networks it appears that clinical reminders 

increase rates of brief alcohol counseling at 

sites where primary care providers are 

required to use clinical reminders. 

In conclusion, we expect that successful 

implementation of brief alcohol counseling 

will require a national performance measure for brief alcohol counseling, and that 

the optimal approach to both implementing 

and monitoring this evidence-based practice may be a standardized national clinical 

reminder. Such a reminder would provide 

education and decision-support to providers 

regarding important components of brief 

alcohol counseling, while simultaneously 

sending data to a central database for performance monitoring at the level of the 

Network or facility. ■ 

References 

Bradley KA, Kivlahan DR, Zhou XH, et al. 

Using alcohol screening results and treatment history to assess the severity of at-risk 

drinking in VA primary care patients. 

Alcoholism: Clinical and Experimental 

Research 2004; 28(3):448-55. 

Maciosek MV, Coffield AB, Edwards NM, et 

al. Priorities among effective clinical preventive services: results of a systematic 

review and analysis. American Journal of 

Preventive Medicine 2006; 31(1):52-61. 

FORUM 

Geraldine McGlynn, Editor-in-Chief 

Margaret Trinity, Editor 

Editorial Board 

Martin P. Charns, D.B.A., Director, VA HSR&D 

Center of Excellence, Boston, MA 

Phil Crewson, Ph.D., Assistant Director, 

VA HSR&D, Central Office 

Joseph Francis, M.D., M.P.H., Acting Deputy 

Chief Research and Development Officer, 

Associate Director, HSR&D QUERI, Central 

Office 

Rodney A. Hayward, M.D., Director, VA HSR&D 

Center of Excellence, Ann Arbor, MI 

Shirley Meehan, M.B.A., Ph.D., Acting Director, 

VA HSR&D, Central Office 

Michael J. Miller, M.D., Ph.D., Chief Medical 

Officer, VA Network #1, Bedford, MA 

Eugene Z. Oddone, M.D., M.H.Sc., Director, 

VA HSR&D Center of Excellence, Durham, NC 

Alan S. Perry, M.H.A., FACHE, Director, 

VA Central California Health Care System