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1.  Multimethod Evaluation of the VA’s Peer-to-Peer Toolkit for Patient-Centered Medical Home Implementation 
Journal of General Internal Medicine  2014;29(Suppl 2):572-578.
Effective implementation of the patient-centered medical home (PCMH) in primary care practices requires training and other resources, such as online toolkits, to share strategies and materials. The Veterans Health Administration (VA) developed an online Toolkit of user-sourced tools to support teams implementing its Patient Aligned Care Team (PACT) medical home model.
To present findings from an evaluation of the PACT Toolkit, including use, variation across facilities, effect of social marketing, and factors influencing use.
The Toolkit is an online repository of ready-to-use tools created by VA clinic staff that physicians, nurses, and other team members may share, download, and adopt in order to more effectively implement PCMH principles and improve local performance on VA metrics.
Multimethod evaluation using: (1) website usage analytics, (2) an online survey of the PACT community of practice’s use of the Toolkit, and (3) key informant interviews.
Survey respondents were PACT team members and coaches (n = 544) at 136 VA facilities. Interview respondents were Toolkit users and non-users (n = 32).
For survey data, multivariable logistic models were used to predict Toolkit awareness and use. Interviews and open-text survey comments were coded using a “common themes” framework. The Consolidated Framework for Implementation Research (CFIR) guided data collection and analyses.
The Toolkit was used by 6,745 staff in the first 19 months of availability. Among members of the target audience, 80 % had heard of the Toolkit, and of those, 70 % had visited the website. Tools had been implemented at 65 % of facilities. Qualitative findings revealed a range of user perspectives from enthusiastic support to lack of sufficient time to browse the Toolkit.
An online Toolkit to support PCMH implementation was used at VA facilities nationwide. Other complex health care organizations may benefit from adopting similar online peer-to-peer resource libraries.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2738-0) contains supplementary material, which is available to authorized users.
PMCID: PMC4070245  PMID: 24715401
primary care redesign; patient-centered care; evaluation; implementation research; quality improvement
2.  Assessing the impact of academic-practice partnerships on nursing staff 
BMC Nursing  2015;14:28.
The ‘spillover effect’ of academic-practice partnerships on hospital nursing staff has received limited attention. In 2007, the Department of Veterans Affairs (VA) created the VA Nursing Academy (VANA) to fund fifteen partnerships between schools of nursing and local VA healthcare facilities. In this paper, we examine the experiences of the VA staff nurses who worked on the units used for VANA clinical training.
We used survey methods to collect information from staff nurses at all active VANA sites on their characteristics, exposure to the program’s clinical training activities, satisfaction with program components, and perspectives of the impact on their work and their own plans for education (N = 314). Our analyses utilized descriptive statistics and bivariate and multivariate regression.
Results show that staff nurses working on VANA units had moderately high levels of exposure to the program’s clinical education activities, and most reported positive experiences with those activities. The vast majority (80 %) did not perceive the presence of students as making their work more difficult. Among those who were enrolled or considering enrolling in a higher education program, over a quarter (28 %) said that their VA’s participation in VANA had an influence on this decision.
The majority of staff nurses were generally satisfied with their experience with the students. Their satisfaction with the program was related to the level or dose of their exposure to it. Those who were more involved were more satisfied. Greater interaction with the students, more information on the program, and a preceptor role were all independently associated with greater program satisfaction.
Our study suggests that academic-practice partnerships may have positive spillover effects on staff nurses who work on clinical education units. Further, partnerships may be able to foster positive experiences for their unit nurses by focusing on informing and engaging them in clinical training activities. In particular, our results suggest that academic-practice partnerships should keep unit nurses well informed about program content and learning objectives, encourage frequent interaction with students, involve them in partnership-related unit-based activities, and urge them to become preceptors for the students.
Electronic supplementary material
The online version of this article (doi:10.1186/s12912-015-0085-7) contains supplementary material, which is available to authorized users.
PMCID: PMC4430985  PMID: 25977641
Nursing education; Partnerships; Nursing Staff; VA Nursing Academy
3.  The development of prospective memory across adolescence: an event-related potential analysis 
Prospective memory (PM) is an important cognitive function vital for day-to-day functioning. Although there has been extensive research into the decline of PM in older adulthood, little is known about its developmental trajectory throughout adolescence, a time of important brain maturation. In the present study, the development of PM was examined in 85 participants across the following groups: 12 to 13-year-olds (n = 19), 14 to 15-year-olds (n = 21), 16 to 17-year-olds (n = 19), and 18 to 19-year-olds (n = 26). A 30-cue (30 min) event-based PM task (with font-color stimuli as PM cues and a lexical-decision task as the ongoing task) was used while recording Event-Related Potentials (ERPs). The well-established neural correlates of PM, the N300 and parietal positivity, were examined across the age groups. In addition, hierarchical multiple regressions were used to examine the unique contribution of executive functioning measures (viz., the Self-Ordered Pointing Task [SOPT], the Stroop task, and Trail Making Test [TMT]) on the ERP components of PM (after controlling for age). First, the established components of ERPs associated with prospective remembering (i.e., N300 and parietal positivity) were detected for each age group. Second, although there were no significant age- group differences on the amplitude of the N300, the amplitude of the parietal positivity was found to be different between the 12 to 13-year-olds and 18 to 19-year-olds (viz., the 12 to 13-year-olds had the highest amplitude). Third, for the contribution of executive functioning measures on the amplitude of the ERP components of PM, the regression on the N300 was not significant, however, the SOPT beta weights were significant predictors of the amplitude of the parietal positivity. This relationship was found to be specific for the central and right electrode region. These findings are discussed within the context of brain development and executive functioning along with particular task demands, which may contribute to age-related PM differences across adolescence. Moreover, the findings suggest that cognitive processes associated with parietal positivity may continue to develop across adolescence.
PMCID: PMC4475796  PMID: 26157379
prospective memory; adolescence; ERPs; executive functioning; cognitive development
4.  The critical elements of effective academic-practice partnerships: a framework derived from the Department of Veterans Affairs Nursing Academy 
BMC Nursing  2014;13:183.
The nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year.
We conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement.
We emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care.
Developing an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.
PMCID: PMC4279967  PMID: 25550686
5.  The Impact of Integrated HIV Care on Patient Health Outcomes 
Medical care  2009;47(5):560-567.
Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have co-morbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers.
Evaluate effect of Integrated HIV Care on suppression of HIV replication.
Research Design
A retrospective cohort study of HIV patients from five Veterans Affairs healthcare facilities 2000–2006.
Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART.
We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of Integrated HIV Care utilization. We evaluated effect of Integrated HIV Care utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.
The 1,018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had co-morbidities with mean 3.2 co-morbidities per patient (S.D.=2.0); 52% achieved viral suppression in median 231 days (S.D.=411.6). Patients visiting clinics which offered hepatitis, psychiatric, psychological and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (Hazard ratio=3.1, p<.001).
Patients who visited Integrated HIV Care clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.
PMCID: PMC3108041  PMID: 19318998
6.  A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration 
Journal of General Internal Medicine  2008;23(8):1200-1207.
Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing.
To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing.
Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program.
Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection
Pre- to post-changes in the rates of HIV testing at the intervention and control facilities
At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities.
Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention’s goal of having every American know their HIV status as a matter of routine clinical practice.
PMCID: PMC2517965  PMID: 18452045
diagnosis; HIV testing; quality improvement
7.  Improving HIV Screening and Receipt of Results by Nurse-Initiated Streamlined Counseling and Rapid Testing 
HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran’s Affairs Healthcare System.
We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing.
Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing).
Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area).
Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement.
Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods.
Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.
PMCID: PMC2517869  PMID: 18421508
nurse-initiated HIV screening; HIV rapid testing; streamlined counseling
8.  Measuring persistence of implementation: QUERI Series 
As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses.
This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).
PMCID: PMC2390585  PMID: 18430200
9.  Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series 
We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis – a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.
Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA.
Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.
Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3–5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.
This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).
PMCID: PMC2335105  PMID: 18353185
10.  Lessons Learned about Implementing Research Evidence into Clinical Practice: Experiences from VA QUERI 
Journal of General Internal Medicine  2006;21(Suppl 2):S21-S24.
The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.
PMCID: PMC2557131  PMID: 16637956
implementation research; quality improvement; evidence-based medicine; guidelines
11.  The Role of Formative Evaluation in Implementation Research and the QUERI Experience 
Journal of General Internal Medicine  2006;21(Suppl 2):S1-S8.
This article describes the importance and role of 4 stages of formative evaluation in our growing understanding of how to implement research findings into practice in order to improve the quality of clinical care. It reviews limitations of traditional approaches to implementation research and presents a rationale for new thinking and use of new methods. Developmental, implementation-focused, progress-focused, and interpretive evaluations are then defined and illustrated with examples from Veterans Health Administration Quality Enhancement Research Initiative projects. This article also provides methodologic details and highlights challenges encountered in actualizing formative evaluation within implementation research.
PMCID: PMC2557128  PMID: 16637954
process assessment (health care); evaluation methodology; evaluation studies
12.  Role of "external facilitation" in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration 
Facilitation has been identified in the literature as a potentially key component of successful implementation. It has not, however, either been well-defined or well-studied. Significant questions remain about the operational definition of facilitation and about the relationship of facilitation to other interventions, especially to other change agent roles when used in multi-faceted implementation projects.
Researchers who are part of the Quality Enhancement Research Initiative (QUERI) are actively exploring various approaches and processes, including facilitation, to enable implementation of best practices in the Veterans Health Administration health care system – the largest integrated healthcare system in the United States. This paper describes a systematic, retrospective evaluation of implementation-related facilitation experiences within QUERI, a quality improvement program developed by the US Department of Veterans Affairs.
A post-hoc evaluation was conducted through a series of semi-structured interviews to examine the concept of facilitation across several multi-site QUERI implementation studies. The interview process is based on a technique developed in the field of education, which systematically enhances learning through experience by stimulating recall and reflection regarding past complex activities. An iterative content analysis approach relative to a set of conceptually-based interview questions was used for data analysis.
Findings suggest that facilitation, within an implementation study initiated by a central change agency, is a deliberate and valued process of interactive problem solving and support that occurs in the context of a recognized need for improvement and a supportive interpersonal relationship. Facilitation was described primarily as a distinct role with a number of potentially crucial behaviors and activities. Data further suggest that external facilitators were likely to use or integrate other implementation interventions, while performing this problem-solving and supportive role.
Preliminary Conclusions
This evaluation provides evidence to suggest that facilitation could be considered a distinct implementation intervention, just as audit and feedback, educational outreach, or similar methods are considered to be discrete interventions. As such, facilitation should be well-defined and explicitly evaluated for its perceived usefulness within multi-intervention implementation projects. Additionally, researchers should better define the specific contribution of facilitation to the success of implementation in different types of projects, different types of sites, and with evidence and innovations of varying levels of strength and complexity.
PMCID: PMC1635058  PMID: 17049080

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