Identifying, Replicating, and Spreading Health care Innovations across a Nation‐Wide Health care System: VHA Diffusion of Excellence
Authors: Jackson G. , Cutrona S. , White B. , Reardon C. , Orvek E. , Nevedal A. , Lindquist J. , Gifford A. , King H. , DeLaughter K. , Henderson B. , Vega R. , Damschroder L. 
Published: August 2020

Research ObjectiveLarge health care systems and organizations face the challenge of identifying, replicating, and spreading evidence‐based innovation across health care system locations. The Diffusion of Excellence (DoE) program aims to incentivize implementing and spreading innovations across the nationwide Veterans Health Administration (VHA). VHA frontline staff submit successfully implemented innovations/practices to a “Shark Tank” competition, in which VHA facility directors place bids to support further implementation. DoE designates the best submission as Gold Status Practices (GSPs), and “winning” bidders receive 6‐months of external facilitation to implement their GSP. DoE then provides national support for diffusing successful GSPs across the VHA. We present results from a mixed‐methods evaluation focused on motivations for program participation, adopting innovations, predictors of implementation, and innovation maintenance/sustainability.Study DesignThe evaluation utilizes the Consolidated Framework for Implementation Research (CFIR). Data sources include: (a) metrics on innovation adoptions linked to VHA facility characteristics; (b) tracking of project specific metrics for practices receiving intensive support for national spread (e.g., potential costs averted, individuals served); (c) 2 focus groups with bidders; (d) observations of 7 DoE events; (e) 143 participants in semi‐structured interview of facility leaders, innovation developers, teams implementing Shark Tank innovations, and implementation facilitators; and (f) 4 surveys of DoE stakeholders. Results are summarized based on the RE‐AIM (Reach‐Effectiveness‐Adoption‐Implementation‐Maintenance) evaluation framework.Population StudiedInnovations aimed at 146 VHA facilities/individual health care systems.Principal FindingsREACH—In the first four Shark Tank rounds, 1676 promising innovations/practices were submitted, with 47 designated as GSPs. EFFECTIVENESS—The impact of specific practices varied. However, impacts have been associated with greater use of evidence‐based services and improved administrative functioning. ADOPTION—Motivations for participating in the DoE process varied among individuals with key roles. Innovations frequently arose from “passion” projects to address identified issues. VA facility/medical center leaders often focus on “big picture” quality metrics and getting middle manager support. Front‐line staff varied in their motivation to implement new projects, potentially leading to a mismatch in stakeholder motivation. IMPLEMENTATION success—approximately half of facilitated‐implementation efforts were fully successful. CFIR themes of Engaging Key Stakeholders and Available Resources received ratings that varied based on level of successful implementation (i.e., fully, partially, or not successful). While sites reported some degree of concern with External Policies and Incentives (e.g., challenges quickly hiring staff), all tried to overcome these challenges with the assistance of External Change Agents (e.g., facilitators and practice developers). MAINTENANCE—At the facility‐level, 74% of facilities originating or receiving facilitated‐implementation support have maintained the practice, including facilities that may have taken longer than 6 months for initial implementation. VHA‐wide, 834 decisions to adopt GSPs have been documented.ConclusionsDoE’s innovative Shark Tank approach identified a large number of candidate practices, successfully promoted adoption of promising practices by facility directors, and supported practice implementation and diffusion across VHA.Implications for Policy or PracticeAs health systems grow in size and complexity, they face additional challenges in identifying, prioritizing, replicating, and spreading best practices. DoE offers a potential model for other health systems and can be a key strategy to move toward being a learning health system.Primary Funding SourceDepartment of Veterans Affairs.