Aligning quality improvement efforts and policy goals in a national integrated health system.

OBJECTIVE: To describe the design and impact of a systematic, enterprise-wide process for engaging US Department of Veterans Affairs (VA) leadership in prioritizing scarce implementation and evaluation resources. DATA SOURCES: From 2017 to 2021, the VA Quality Enhancement Research Initiative (QUERI) identified priorities from local, regional, and national leaders through qualitative discussions and a national survey and tracked impacts via reports generated from competitively funded initiatives addressing these priorities. STUDY DESIGN: Guided by the Learning Health System framework and QUERI Implementation Roadmap, QUERI engaged stakeholders to nominate and rank-order priorities, peer-reviewed and funded initiatives to scale up and spread evidence-based practices (EBPs) using theory-based implementation strategies, and evaluated the impact of these initiatives using the QUERI Impact Framework. DATA COLLECTION/EXTRACTION METHODS: QUERI collected priority nominations through qualitative discussions and a web-based survey, and live voting was used to rank-order priorities. QUERI-funded teams regularly submitted progress reports describing the key activities, findings, and impacts of the quality improvement (QI) initiatives using a standardized form created in the VA Research Electronic Data Capture (REDCap). PRINCIPAL FINDINGS: QUERI launched five QI initiatives to address priorities selected by VA leadership. In partnership with 28 health system leaders, these initiatives are implementing 10 EBPs across 53 sites, supporting 1055 VA employees in delivering evidence-based care. The success of these initiatives led to an expansion of QUERI's process to address 2021 VA leadership priorities: virtual care, health disparities, delayed or suppressed care due to COVID-19, employee burnout, long-term and home care options, and quality and cost of community care. CONCLUSIONS: QUERI, a unique program embedded in a national integrated health system, deployed a novel approach to inform policy making and enhance the real-world impact of research through prioritization of limited resources, rigorous peer-review, and assessment of impacts on the health system, employees, and Veterans.

Design and implementation of a cluster randomized trial measuring benefits of medical scribes in the VA.

BACKGROUND: Medical scribes are trained professionals who assist health care providers by administratively expediting patient encounters. Section 507 of the MISSION Act of 2018 mandated a 2-year study of medical scribes in VA Medical Centers (VAMC). This study began in 2020 in the emergency departments and specialty clinics of 12 randomly selected VAMCs across the country, in which 48 scribes are being deployed. METHODS: We are using a cluster randomized trial to assess the effects of medical scribes on productivity (visits and relative value units [RVUs]), wait times, and patient satisfaction in selected specialties within the VA that traditionally have high wait times. Scribes will be assigned to emergency departments and/or specialty clinics (cardiology, orthopedics) in VAMCs randomized into the intervention. Remaining sites that expressed interest but were not randomized to the intervention will be used as a comparison group. RESULTS: Process measures from early implementation of the trial indicate that contracting may hold an advantage over direct hiring in terms of reaching staffing targets, although onboarding contractor scribes has taken somewhat longer (from job posting to start date). CONCLUSIONS: Our evaluation findings will provide insight into whether scribes can increase provider productivity and decrease wait times for high demand specialties in the VA without adversely affecting patient satisfaction. IMPLICATIONS: As a learning health care system, this trial has great potential to increase our understanding of the potential effects of scribes while also informing a real policy problem in high wait times and provider administrative burdens.