A Publication of the VA Office of Research & Development, Health Services Research & Development Service,

Management Decision and Research Center, in conjunction with the Academy for Health Services Research

and Health Policy

continued on page 2

The VA Quality Enhancement Research

Initiative: Building Systems for

Evidence-Based Practice and Policy

By Lynn McQueen, D.P.H., R.N., and John G. Demakis, M.D.

FORUM

VA HEALTH SERVICES RESEARCH & DEVELOPMENT NOVEMBER 2000

When the VA launched the Quality

Enhancement Research Initiative

(QUERI) in 1998, it was with the

specific goal of making quality

improvement an integral part of

system-wide change. From the

start, QUERI has served as a

bridge between research and clinical practice, nurturing a dynamic

culture of critical thinking and continuous learning across professional and organizational groups. This

is precisely the culture needed to

achieve VA’s vision of excellence –

a vision that is now bearing fruit.

QUERI has formalized processes

that promote evidence-based

health care while at the same time

refining and honing our research

agenda. There are eight QUERI

groups, each of which focuses on a

clinical condition with a high level

of prevalence or risk among VA

patients (see box on page 3). For

each condition, the QUERI

research and clinical leaders use a

six-step process (see box on page 3)

to identify what we know about the

state-of-the-art in quality improvement and put that knowledge into

clinical practice. It is a way of systematizing quality improvement at

the national level. 

In keeping with the Strategic

Framework for Quality Management

initiated throughout VA in the mid1990s, by then-Under Secretary

Kenneth W. Kizer, M.D., M.P.H.,

QUERI merges the complex, interwoven processes that support evidence-based decision making. 

The QUERI mission to translate

research discoveries and innovations into better patient care and

systems improvements can only be

fully achieved over time and in

stages. Still, the power of research

becomes most striking when a

QUERI group takes a strong finding (either original or published

best practice information) and

implements a plan to take this evidence to the bedside and to the policy table. QUERI translation

activities not only assure that findings reach decision makers and

promote targeted interventions,

but also follow up to see that their

impact is measured and reported. 

For example, the Spinal Cord

Injury (SCI) QUERI is seeking to

improve outcomes for veterans

with SCI by focusing on preventive

health practices. Its first goal is to

increase influenza vaccination

rates in the VA SCI population.

Because pulmonary conditions are

C DIRECTOR’S LETTER OMMENTARY

The year 2000 has been an extremely

productive and successful one for

HSR&D. Through a diverse and

creative research portfolio that

includes 149 ongoing funded projects, HSR&D researchers are focusing on a broad array of important

health issues affecting veterans

and the nation. Among the highpriority areas targeted by HSR&D

research are access to care, patient

safety, telemedicine, and the implementation of clinical practice

guidelines. HSR&D investigators

have had more than 1,500 publications in FY 2000. In addition we

have increased our dissemination

efforts to make sure findings get to

managers and policy makers in a

timely and accessible manner. 

We’ve also been building our

research capacity through our

Career Development programs.

Fifty-eight clinicians and Ph.D.

scientists were given awards this

year to continue research that will

have a positive impact on the quality of veterans health care.

Last but not least, there is the

Quality Enhancement Research

Initiative (QUERI). This groundbreaking initiative, to which this

issue of FORUM is dedicated,

focuses on translating research

results into practice so that quality

improvement will become systematized. Beginning its third year,

QUERI is fast becoming a national model for quality improvement.

While 2000 continues to be an

incredible year, 2001 holds even

greater promise. We look forward

to expanding our management

research portfolio and to making

great strides in quality improvement through QUERI. Our journey of continuous learning and

advancement is well underway. 

John G. Demakis, M.D.

Director, VA HSR&D Service 

Q UERI has formalized

processes that promote 

evidence-based health care

while at the same time

refining and honing our

research agenda.
2

a leading cause of mortality and

morbidity among SCI patients,

increasing vaccination rates may

reduce complications and other

adverse outcomes from influenza or

pneumonia. A multi-pronged

approach involving patient and

provider interventions (including

tools that promote targeted education and reminders) will be used

and special effort made during the

flu season. Patients will be monitored to see who is offered and

administered a flu vaccine; comparisons will be tracked year to year. 

The impact of vaccination will be

evaluated by linking rates of health

care use to incidence of influenza,

pneumonia, and related respiratory

disorders during each flu season

from 1998 to 2001. Outcome and

process data will be reported. By

preventing respiratory infections,

the SCI QUERI expects to substantially reduce the 37 percent excess

mortality associated with influenza

or pneumonia, and hopes to

enhance both patient quality of life

and cost savings. 

Translation efforts such as those

of the SCI QUERI are planned and

rigorously reviewed prior to execution. The strategies and tools used

to move a research finding into

action are documented in a

Translation Plan that becomes part

of a larger Strategic Plan, which

spells out the scope of work for

each QUERI group. 

Translation strategies include

multifaceted efforts to target key

audiences for seminars and interactive online education, as well as

ongoing initiatives to identify clinical champions and opinion leaders.

These strategies complement the

120 or more tools developed across

QUERI groups to promote use of

research findings. 

Those tools are specifically

designed to make it easier for clinicians to provide good, appropriate

care and harder to stray from evidence-based decision-making.

QUERI tools are quite diverse and

Commentary

continued from page 1

C OMMENTARY

range from simple pocket cards and

posters to highly sophisticated 

decision support systems. 

Tool boxes that combine strategies and tools are also popular and

several are being tested for their

effectiveness in promoting optimal

outcomes. Each Translation Plan

identifies the dissemination, implementation, and evaluation strategies and tools needed to promote

use of findings in everyday practice

situations across the VA:

■ Dissemination. Blanket distribution of information to potential stakeholders is not enough on

its own to effect change.

Dissemination activities communicate important information to targeted audiences in useful formats

and promote interactive learning

and retention. Popular dissemination strategies include interactive

computer programs, web sites,

mailings, and seminars. 

■ Implementation. Once disseminated, multiple implementation activities are launched, using

effective strategies designed for

targeted audiences working within

specific settings. Communication,

education, and administrative

strategies are used to overcome

real and potential barriers.

Facilitating factors are identified

and reinforced. A network of opinion leaders and clinical champions

facilitates implementation.

■ Evaluation. Using scientific

methods, information is collected

and analyzed to determine the

impact, effectiveness, efficiency, relResponse

By Robert A. Petzel, M.D., Director, VA Upper Midwest Network 13

VA is trying to transform itself into a learning organization — a place where we

are continuously re-examining what we know and striving to produce important

new knowledge. This is a difficult task that requires the commitment and

involvement of everyone in VA.

But expanding our knowledge base is really only part of the equation.

Implementation of that knowledge — putting it to practical use — is the other

part. When it comes to improving patient outcomes, the issues of implementation are complex. In fact, the concept of how to put new clinical knowledge into

practice has been studied a great deal recently. The problem is that we have a

better understanding of what doesn’t work than what does. It is clear that the

traditional methods of knowledge diffusion — including conferences, journal

articles, and grand rounds — do not substantially impact medical practice. It is

also clear that publishing guidelines, policies, and regulations does not effectively change the behavior of individual practitioners.

This is where VA’s Quality Enhancement Research Initiative (QUERI) is

playing an important role. QUERI has focused and systematized VA’s efforts to

improve the evidence base for clinical practice. Areas of high risk and high volume have been identified. Baseline practice patterns, outcomes, and variations

from best practices are being defined. Research has been funded and initiated in

a large number of important areas. Spinal cord injury and diabetes are two

areas where this focus has resulted in recommendations for significant changes

in clinical practice.

The literature on how new knowledge is diffused throughout an organization

is growing. A VA group is now engaged in reviewing this literature and trying to

understand how knowledge is diffused up, down, and across our organization.

Researchers, particularly those in our Health Services Research and

Development Service, have a responsibility for developing new information (even

about knowledge diffusion).

Implementation, however, is a team effort. Research, operations, and education all contribute to the diffusion of new knowledge. They must work together.

No one element can do it alone. Likewise, QUERI is an important initiative, but

needs to be a part of this larger effort, so that we are constantly communicating

and applying new knowledge across the VA. This is everyone’s responsibility.

continued on page 3
3

Commentary

continued from page 2

C OMMENTARY

evance, and/or progress of translation activities. Measurable changes

in processes and outcomes are documented and feedback is provided.

Already, QUERI’s success is documented in the research findings

rapidly being generated to fill gaps

in best practices, in the tools being

developed to take QUERI findings

to the bedside, and various publications of QUERI results. But traditional output of this kind is not

sufficient. From the outset, QUERI

participants were expected to demonstrate accountability. It is not enough

to publish findings and move onto

the next study or develop a guideline and assume that it is followed. 

Together, the researchers and

clinicians participating in QUERI go

the next step by implementing findings, measuring the impact of those

evidence-based interventions, and

then reporting on outcome and system improvements. The value of

these findings for improving both

veterans’ health and the VA health

system as a whole is clear. In the

brief time that QUERI has been

operating, several improvements

have been documented. For example, the Diabetes QUERI (in work

done in collaboration with VA’s

Office of Policy and Planning,

Patient Care Services, and the Office

of Quality & Performance) demonstrated that VA surpasses the private sector in many diabetic quality

standards. The diabetes group then

Response

By Jonathan B. Perlin, M.D., Ph.D., M.S.H.A., Chief, 

Office of Quality and Performance

Between research and practice stands the interface between efficacy and effectiveness. Researchers, even health services researchers, have traditionally

focused on the arena of efficacy. In that arena, the world is more orderly.

Within the investigators’ control are the parameters that create the elegant symmetry of placebo-controlled random assignment. As effectiveness studies

humbly remind us, such symmetry is absent in “the real world.” Also missing is

the consistency of support systems that may have influenced efficacy in the

research environment.

What are the limitations of experimental design that diminish successful

generalization from efficacy to effectiveness? What characteristics of the prototype setting are necessary for preliminary success to be achieved in a diversity of

“real-world” clinical environments? And how do we reliably follow the trajectories of practices introduced from research to know if they are falling short, meeting, or even exceeding their promise?

VA’s mission to provide optimal health care to veterans means that achieving

effectiveness is not a luxury, but a prerequisite. VA has articulated its core values as “Value-Domains”: quality, satisfaction, access, maximizing functional

status, efficiency, and building healthy communities. The study, understanding,

and achievement of effectiveness in each “value domain” is our responsibility as

we meet the challenge of delivering maximal health care utility within a defined

budget. This is a challenge for health care even more broadly. The VA system

is an ideal, dynamic, living-laboratory for health services research. We have the

scale, scope, consistency of purpose, and improving information systems. The

brilliance of the VISN approach allows us to “think globally, but act locally” —

often conferring the properties of a natural experiment. What are the unique

local or regional structural differences, or characteristics of processes, that confer the most desirable health outcomes? How can those structural features or

process characteristics be understood or captured for application elsewhere?

And how do we measure most efficiently to ascertain that we are achieving our

goal of significantly improving the health care of veterans?

Between research and practice stands the interface between efficacy and

effectiveness. Between research and practice stand all of the issues and questions posed above. At this interface is the recognition that life is not a randomized controlled trial, but also the recognition of tremendous opportunity in

answering these sorts of questions. As we look forward to much productive

work together, the Office of Quality and Performance applauds the Quality

Enhancement Research Initiative (QUERI) programs for their significant contributions in translating what is learned from the evidence of research to what is

available for the evidence of practice. Fundamentally, QUERI exists at the 

critical interface between research and practice, and QUERI is in just the 

“right place.”

continued on page 8

The QUERI Groups

QUERI focuses on eight conditions due to their high volume and/or high risk among VA patients: chronic heart

failure, diabetes, HIV/AIDS, ischemic heart disease, mental health, spinal cord injury, stroke, and substance abuse.

Steps in the QUERI Process:

1. Identify high-risk/high volume diseases or problems.

2. Identify best practices.

3. Define existing practice patterns and outcomes across VA and current variation from best practices.

4. Identify and implement interventions (including performance criteria) to promote best practices.

5. Document that best practices improve outcomes.

6. Document that outcomes are associated with improved health-related quality of life.
4

R ESEARCH HIGHLIGHT

QUERI Lipid Project Helps Chart Course for Better Treatment

of Patients with Ischemic Heart Disease

By Ann Sales, M.S.N., Ph.D, Sandra Pineros, M.P.H., P.A.C., Helene Starks, M.P.H., and Haili Sun, Ph.D. 

Findings from the Lipid

Measurement and Management

System, a rapid-response project

within the Quality Enhancement

Research Initiative in Ischemic

Heart Disease (QUERI-IHD), illustrate the potential for research to

influence both clinical practice and

policy. The objective of the QUERIIHD is to improve outcomes of veterans with IHD using health services research methods to identify,

implement, and evaluate interventions to improve compliance with

national treatment guidelines. 

VA guideline recommendations

for secondary prevention of IHD

include lipid measurement for all

veterans with IHD and serum LDL

cholesterol level less than 100

mg/dL. The Lipid Measurement

and Management System project

was designed to define variations in

practice and outcomes within and

across veterans integrated service

networks (VISNs). We identified

patients with IHD, determined

whether their lipid levels were

being measured, defined lipid-lowering therapies, and compared lipid

levels among VA patients with

national guideline-specified standards. In the process, we demonstrated variations in practice across

VISNs 1, 16, 20 and the Cincinnati

Veterans Ambulatory Medical

Center. By combining electronic

data from multiple sources, we

were able to define current practice, guideline compliance, and variation in care without chart

abstraction and compare those findings within and across VISNs. 

Our study included 24 medical

centers in four VISNs. We identified 41,366 veterans with IHD

across all study sites — roughly 10

percent to 12 percent of all veterans

treated in VA facilities. This is

actually a conservative estimate,

because of the design of our identification algorithm. On average, we

found that 66 percent of patients

with IHD were current on their

LDL tests. The lowest rate for a

VISN was 56 percent; the highest

was 72 percent The range across

medical centers was much higher:

38 percent to 82 percent. All of

these differences are statistically

significant. In each case, thousands

of veterans are affected. 

The percentage of patients

receiving some kind of drug therapy

to lower LDL was relatively similar

across VISNs, ranging from 56 percent to 58 percent. This suggests

two things. First, some patients

are being treated without a current

LDL measurement in the clinical

information system. Second, there

is less variation at the VISN level

for lipid-lowering therapy than for

LDL measurement. This difference

is statistically significant, but may

not be as clinically significant or

important for policy than the difference in LDL measurement.

However, there is considerably

more variation among medical facilities than among VISNs in the percentage of patients — 35 percent to

68 percent — receiving lipid-lowering agents.

Finally, we examined the proportion of patients who have attained

the guideline-recommended LDL

goal of 100 mg/dL or less. The proportion of patients attaining this goal

across VISNs varied from 40 percent

to 46 percent. This difference is also

statistically significant, as well as

clinically significant, since it again

affects thousands of veterans.

Variation across medical centers was

even more extreme, ranging from 34

percent to 53 percent 

Our findings have considerable

clinical and policy relevance. The

gap between what is recommended

in clinical guidelines and what is

actually done in practice is significant — both for measuring LDL

levels and treating with lipid-lowering drugs. Of particular concern

are the differences among medical

centers in the proportion of IHD

patients who attain the recommended goal of 100 mg/dL or less.

It is difficult to find appropriate

benchmarks in the private sector,

but the highest rate of goal attainment that we found, 53 percent, is

still regarded as low compared with

best practices in the private sector. 

Based on these findings, we recommend putting more resources

into LDL measurement, which is

the first step in assessing an IHD

patient’s risk for recurrent events.

The gap in performance here is

very stark. It may be possible to

begin to address the second step,

initiating and then optimizing drug

therapy, as rates of LDL measurement improve. 

Improvement on these measures

is both possible and necessary. The

benefits to veterans are clear in

terms of lowered disease burden,

improved quality of life, and

enhanced longevity. The benefits

to VA are also clear. Cost savings

will derive largely from decreased

admissions for heart attack and

unstable angina. In an integrated

delivery system, it should be possible to adjust costs and savings so

that both the system and its

patients benefit.

For more information, please

contact Helene Starks at 206/764-

2868, email Helene.Starks@med.

va.gov .

W e recommend putting

more resources into LDL

measurement, which is the

first step in assessing an

IHD patient’s risk for

recurrent events.
5

R ESEARCH HIGHLIGHT

Cross-Cutting QUERI Project Targets Determinants of 

Clinical Guideline Implementation Effectiveness

By Bradley N. Doebbeling, M.D., M.Sc., Iowa City VAMC and University of Iowa; Bonnie J. BootsMiller, Ph.D., 

Iowa City VAMC; Thomas Vaughn, Ph.D., and Marcia Ward, Ph.D., University of Iowa 

Successful application of new

research findings to clinical practice

requires effective implementation

strategies. Identifying such strategies is not as easy as it sounds.

Within a given organization, structural characteristics, managerial

attitudes, and relationships with

outside entities all influence the

structure, process, and outcome of

implementation strategies.

At the VA, a cross-cutting project

of the Quality Enhancement

Research Initiative (QUERI) based

at the Iowa City Veterans Affairs

Medical Center (VAMC) is exploring

factors that affect compliance in VA

facilities nationwide with VA clinical

practice guidelines. 

We are examining the relationship of effective guideline implementation to VA facilities’ organizational

characteristics, implementation

structures, and processes. Further,

we are investigating these factors

and effects across several guidelines

to explore how characteristics of

each guideline affect implementation

and adherence. 

The specific aims of our research

are to:

■ Describe rates of adherence with

current VA clinical practice guidelines in VA acute care facilities. 

■ Identify provider and manager

level factors associated with effective guideline implementation

using focus groups and individual

interviews.

■ Identify organizational structures and processes as well as characteristics of implementation work

groups that are associated with timely and effective dissemination of and

adherence with clinical guidelines

within VA facilities nationally.

■ Develop and validate predictive

models of the relationships among

facility organizational characteristics; guideline characteristics; and

measures of the guideline implementation process and outcomes,

with an emphasis on provider

adherence.

This is a multi-method, quasiexperimental national study using

qualitative and quantitative

research methods to analyze the

process of guideline implementation. VA medical centers nationwide have been selected to

represent a range of geographic,

bed-size, teaching affiliation, and

patient population (gender and

racial/ethnic) distributions. In this

first phase, we have been conducting focus groups and interviews of

primary care administrators,

providers, and staff at selected

facilities. Currently, we have completed 50 focus groups in 18 facilities. These groups have helped us

to better understand the process of

clinical guideline implementation

and to identify important barriers

and facilitators and have informed

development of a survey for the second phase of the project. Based on

our work to date, compliance

appears to be influenced by the

organizational culture, implementation process, characteristics of

the guideline itself, and by rewards

and sanctions at the organizational

level. The qualitative data have

enhanced our understanding of

guideline implementation efforts

and informed development of a survey

for the second phase of the project.

In Phase 2, performance

improvement coordinators and midCareer Development Awardees Graduate,

Continue Work

Three members of HSR&D’s fourth class of Career Development

awardees graduated this summer. Sam Bozzette, Raul Garcia, and

Dawn Provenzale all started at the entry level in 1994, progressed

through the program and are now successful independent investigators

assuming mentoring and other leadership roles at their facilities. 

Sam Bozzette, M.D., Ph.D., remains on staff at the San Diego VA

Medical Center. Sam has been involved in HIV/AIDS research since

the start of his Career Development award, and has produced many

publications from this work (one of which earned an “Article of the

Year” award from the Association for Health Services Research). He

currently heads the HIV Research Coordinating Center for the Quality

Enhancement Research Initiative (QUERI). 

Raul Garcia of the Boston VA Medical Center is the first dentist to

complete the program, and has served as mentor for other dentist awardees.

He is principal investigator for a project that ended in October. 

Dawn Provenzale, M.D., M.S., remains on staff at the Durham VA

Medical Center. Dawn is a successful HSR&D principal investigator

who is continuing the work she began under her Career Development

award, studying screening and surveillance techniques for gastrointestinal malignancies, including esophageal carcinoma and colon cancer. Dawn has been an active mentor and is working to develop a

training program for GI fellows interested in health services research. 

continued on page 8
6

R ESEARCH HIGHLIGHT

QUERI Researchers Evaluate Automated Telephone 

Assessment and Patient Education as a Strategy for 

Improving VA Diabetes Care

By John D. Piette, Ph.D., Center for Health Care Evaluation, VA Palo Alto Health Care System

Although systematic patient followup is fundamental to effective diabetes management, VA providers

frequently lack accurate and timely

information about their patients’

glycemic control, health status, and

self-care. Time pressures often

make comprehensive assessments

impossible during outpatient visits,

and many patients lack education

in self-management. 

These problems take on added

significance for patients who,

because of access barriers, do not

receive regular outpatient care.

Although research has shown that

telephone care can improve access,

such programs can be laborintensive and difficult to implement

effectively in large health care systems like VA.

VA’s Quality Enhancement

Research Initiative Diabetes Module

(QUERI-DM) is evaluating the

potential for automated telephone

care to improve diabetes treatment

within VA. Using voice-recognition

technology, automated telephone

disease management (ATDM) programs allow patients to report information about their health status and

health behaviors between clinic 

visits. Based on their reports,

patients receive tailored ATDM educational messages and follow-up by a

telephone care nurse or primary

care team. The intervention is

designed to improve diabetes treatment outcomes by enhancing the

quality of information available for

clinical decision-making, promoting

more rational allocation of treatment resources, and helping

patients perform self-care activities.

Research Shows 

Positive Results

Previous studies indicate that diabetes patients will respond to

ATDM calls over an extended period of time, report reliable information via ATDM, and choose

optional ATDM self-care education

messages. In one study, VA

patients receiving ATDM calls

with nurse follow-up for one year

reported better self-care than randomized controls, were more likely

to have had their cholesterol tested

(87 percent versus 78 percent), and

were more likely to be seen in podiatry clinics (62 percent versus 42

percent). Among patients with

baseline HgA1c levels greater than

9 percent, mean endpoint values

for intervention and control

patients were 9.2 percent and 10.2

percent respectively. Finally,

intervention recipients at followup reported fewer symptoms than

control patients and were more

satisfied with their VA care. These

findings corroborate results from a

prior trial conducted in a county

health care system. 

The current QUERI-DM study

is assessing an enhanced version of

an ATDM system developed through

prior research. In Phase 1 of the

study, we are developing ATDM

assessment instruments for monitoring a range of patient outcomes,

including symptoms, self-care,

health-related quality of life, and 

satisfaction with VA care. Eight

hundred patients from two veterans

integrated service networks (VISNs),

VISN 12 and VISN 21, are receiving

weekly ATDM assessments for six

months. Other data are being collected quarterly via laboratory testing,

chart review, surveys, and utilization

databases. Analyses focus on the reliability and validity of ATDM assessment data. We also are examining

variations in ATDM-reported outcomes across networks, facilities, and

sociodemographic groups. Most

importantly, we are evaluating the

extent to which ATDM assessment

information can help clinicians better

identify patients at greatest risk for

developing acute illnesses and complications. 

QUERI Conducts “Real

World” Test 

In the second phase of the study,

we will use the findings from our

process evaluation to modify the

ATDM assessments and design

provider feedback reports. We will

enroll 120 patients from each of

four participating facilities and use

a randomized design to evaluate the

impact of ATDM assessment and

self-care education calls with clinician follow-up. In contrast to prior

efficacy studies in which ATDM follow-up was provided by a study

nurse, this effectiveness trial will

determine whether ATDM is beneficial when follow-up is conducted

by “real-world” VA clinicians.

Endpoints for the trial include

glycemic control and patient-centered outcomes, such as symptoms

and satisfaction with VA care. Cost

analyses will focus mainly on VA

costs, although costs reported in

Medicare claims files also will be

examined. 

In summary, this study will

determine whether an ATDM

assessment and self-care education

system is an effective strategy for

monitoring the health of large panels

A lthough research has

shown that telephone care

can improve access, such

programs can be laborintensive and difficult to

implement.

continued on page 8
7

Martin P. Charns, D.B.A., Editor-in-Chief

Mary Darby, Editor

Geraldine McGlynn, Co-editor

ADVISORY COMMITTEE

John G. Demakis, M.D., Director, VA HSR&D

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

Center of Excellence, Ann Arbor

David H. Law, M.D., VA Medical Center, 

Bay Pines, FL

Shirley Meehan, M.B.A., Ph.D., VA HSR&D

Alan S. Perry, M.H.A., FACHE, VA Medical

Center, Fresno, CA

Robert M. Roswell, M.D., VA Network #8,

Bay Pines, FL

Hanna B. Rubins, M.D., M.P.H., VA HSR&D

Center of Excellence, Minneapolis

Forum is a Publication of the VA Office of Research &

Development, Health Services Research & Development

Service, Management Decision and Research Center, in

conjunction with the Academy for Health Services Research

and Health Policy.

F O R U M

Dr. Kevin Weiss Takes Helm 

at Midwest Center of Excellence

The Midwest Center for Health

Services and Policy Research (MCHSPR), one of HSR&D’s 11 Centers of

Excellence, has recently welcomed a

new director, Kevin B. Weiss, M.D.,

M.P.H., M.S.

Prior to joining VA, Dr. Weiss was

an associate professor of internal medicine at the Rush Medical College and

director of the Center for Health

Services Research at the Rush Primary

Care Institute, Rush-Presbyterian-St.

Luke’s Medical Center, Chicago, Ill.

Previously, he was associate professor

of health care sciences and medicine at

the George Washington University

Medical Center in Washington, D.C.

and research fellow at the Center for

Health Policy Research at George

Washington University. He has also

held positions at the National Center for Health Statistics of the Centers

for Disease Control and Prevention, and the National Institute of Allergy

and Infectious Diseases (NIAID). He is also a former Robert Wood Johnson

Generalist Physician Faculty Scholar. 

As director, Dr. Weiss plans to build on MCHSPR’s long tradition of

excellence in research both within and beyond the VA system. The next

few years will serve as a springboard for a number of new program goals

and initiatives for the MCHSPR, including increased interaction with universities in the MCHSPR community, stepped-up efforts in collaboration

with other VA hospitals and health services research field programs, as well

as new research initiatives. 

HSR&D Annual Meeting 2001 

Focuses on Access and Outcomes

“VA Health Services Research: Improving Access and Outcomes” will

be the theme of the 19th Annual Meeting of the Health Services

Research and Development Service (HSR&D), to be held Feb. 14-16,

2001, in Washington, D.C. HSR&D’s Center for Chronic Disease

Outcomes Research, located in Minneapolis, will host the meeting,

bringing together researchers, clinicians, and policy makers to discuss

new and important health services research issues. Topics such as

performance monitoring, practice guidelines, evidence-based decisionmaking, and organizational theory will be explored and debated.

Annual Meeting highlights include an opening reception and dinner, a

Proposal Development Workshop, a Special Interest Round Table

Luncheon, and a Pre- and Post-Doctoral/Fellow Poster Competition. 

For more information about HSR&D’s Annual Meeting 2001, visit

http://www.va.gov/hsrd2001/, or email Karen Hickey at

Karen.Hickey@med.va.gov. Deadline for the Annual Meeting registration is Jan. 5, 2001.

HSR&D Announces

New Solicitations

In collaboration with VA’s Office of

Quality and Performance, HSR&D

recently issued two new Special

QUERI Solicitations for Service

Directed Projects (SDPs). The

first, “Translation of Findings into

Practice,” is designed to promote

quality of care by translating existing findings into practice. It covers

both the translation of findings and

the study of translation itself. The

second solicitation, “Translation of

Hypertension Research Findings

into Practice,” targets a serious

problem for countless veterans.

The purpose of this solicitation is to

fund projects that measure the

translation of existing research

findings concerning hypertension

treatment (such as the improvement of blood pressure control)

into practice. New knowledge

about the etiology, diagnosis, or

treatment of hypertension is not

part of this solicitation. 

Concept papers for these solicitations must be received at HSR&D

Headquarters by Friday, Nov. 3.

Proposals are due by Thursday,

Dec. 7. For more information, 

visit the QUERI web site at

http://www.va.gov/resdev/queri.htm.
8

went on to study and refine several

related guidelines. In this way,

QUERI not only influences patient

outcomes and overall quality, but

also promotes positive policy change. 

Goethe observed that “knowing

is not enough: we must apply.

Willing is not enough: we must

do.” In doing so, he demonstrated

an intuitive understanding of what

it takes to improve quality on an

ongoing basis in real situations.

What those participating in

QUERI witness each day is the

complexity involved in enacting

and sustaining practice and system-wide change. 

But the most significant contribution of QUERI may prove to be

even more difficult to measure.

Here, we refer not to clinical practice change but to policy change.

The evolution of a system-wide

approach to quality improvement in

the largest integrated health care

system in the country is opening

the doors and secret passageways

that guard local, regional, and

national policies and their linkages.

As information exchange between

these levels becomes part of the

daily routine, positive actions are

taken and the organization moves

forward. Although QUERI clearly

is producing a tangible output that

is benefiting many patients, its

Commentary

continued from page 3

Guidelines

continued from page 5

most important legacy ultimately

may be in the light it is shedding

on what it takes to systematically

promote sound, evidence-based

policies on an ongoing basis. 

level managers in all VA facilities

will be surveyed to determine what

approaches are being used to implement clinical guidelines. These surveys include questions about the

implementation methods used for

recently mandated guidelines, institutional support, respondents’ attitudes and beliefs about the

usefulness of specific guidelines,

availability of feedback, and provider

adherence, as well as barriers and

new approaches to incorporating

guidelines into clinical practice. 

The final two years of the project

(if funded in a competitive renewal)

will involve an in-depth exploration

of implementation of newly mandated guidelines. Phase 3 will focus on

a subset of VA facilities — those

with high or low rates of adherence

to a range of previously mandated

guidelines. This process evaluation

will involve detailed telephone surveys of a sample of key administrators, mid-level managers, and

clinicians to identify the steps in the

implementation process. Phase 4

will involve a second mailed survey

to all VA facilities to validate earlier

QUERI

continued from page 6

findings on key factors in the implementation process that differentiate

facilities with high and low rates of

adherence. This set of surveys will

be developed for administrators and

practitioners who are involved in the

clinical areas affected by the guidelines that were nationally mandated

during the study year. Analysis of

the results of these surveys will

identify the implementation process

factors that vary across institutions

and the degree to which these factors are associated with adherence.

We believe this project will

advance the QUERI directive of

translating research into practice

and lead to many benefits for VA,

not least of which is improved

health care for veterans. 

of VA patients with diabetes and

circumventing access barriers. By

focusing clinical resources more

effectively and improving patients’

self-care, the intervention may costeffectively improve diabetes outcomes. Moreover, ATDM may be a

useful means of monitoring patientcentered indicators of the quality of

ambulatory care, a dimension of

quality assessment that has been

largely overlooked because of the

difficulties and expense of gathering such information.