The Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) QUERI Program

背景：医疗保健系统面临的挑战是提供尽可能高质量的护理， 同时确保广泛获得服务和谨慎使用资源。没有经过深思熟虑 设计的实施战略，循证实践（EBP）的影响无法充分实现 因为很难将EBP扩展到早期采用的设施之外。扩大医疗保健的可及性， 活动、研究和知识（SHAARK） 与退伍军人事务部高度相关的领域：解决遭受道德痛苦的退伍军人的需求（例如，内疚羞愧 背叛）由于在服役期间采取或不采取的行动（又名，精神伤害）和面临 糖尿病控制持续不佳的重大健康风险。虽然这些群体在 他们自己，来自研究不同的EBP的实施，旨在不同的复杂的协同作用， 健康状况将导致更好地理解如何解决总体实施 将临床EBP转移到卫生系统的挑战。 重要性/影响：与VA机构和VISN总监绩效计划指标保持一致，以识别和 传播创新，SHAARK QUERI将为VA和其他医疗保健系统如何 使用策略将复杂的临床EBP传播到整个医疗保健领域的成功早期采用者之外 系统将通过对符合以下要求的实施策略进行临床试验来获得这些证据： 探索、准备、实施和维持（EPIS）实施框架， 寻求改善对精神伤害和持续不受控制的糖尿病的护理。 具体目标：使用两个EBP，高级综合糖尿病护理（ACDC）和道德伤害组， 我们将进行两项与EPIS框架相一致的第3类混合实施试验， 制定实施循证优先事项的战略。具体目标如下：目标1a：衡量差异 接受适当剂量/坚持分组就诊的患者百分比（≥ 80%的 目标1b：衡量核心组成部分百分比的差异 目标1c：审查对EBP流程的调整数量和 研究中心开展的质量改进工作/计划-实施-研究-行动周期的强度;目标2：检查 PTSD症状、自杀行为和感知生活意义（精神伤害）的变化差异 组试验）和血红蛋白A1 c变化的差异（ACDC试验）;目的3： 目标4：建立一个商业案例，包括预算影响（针对两个EBP试验）。 方法：我们将测试实施策略，动态扩散网络（DDN），用于操作 EPIS（每次试验1个单独的DDN），用于以后采用EBP的人。DDN将与技术 援助.对于每项试验，将随机分配10家VA机构，使用动态 传播网络环境政策信息系统实施战略（5个地点）或技术援助（5个地点）。主要结局 将重点关注电子商务计划的成功实施、电子商务计划组成部分的使用和快速改进 过程，以及实践的次要临床结果。以前用于这两种用途的方案材料 将改进电子商务计划，使之成为一个初步的改革包/实施工具包，与每个感兴趣的人分享。 绝佳的价钱两名有经验的前线人员会评估这些工具包 实施EBPs。我们还将对这两个EBP进行形成性评估，以探索潜在的因素 根据实施研究的综合框架，影响EPIS每个阶段的成果 （CFIR）。评估将采用混合方法，包括半结构化、定性和定量评估。 访谈、调查和其他补充方法。商业案例将是 根据平衡计分卡方法制定，考虑成果、成本和实施。

Background: Healthcare systems face the challenge of delivering care of the highest possible quality while simultaneously ensuring broad access to services and prudent use of resources. Without thoughtfully designed implementation strategies, the impact of evidence-based practices (EBPs) cannot be fully realized because it is difficult to spread the EBP beyond early adopting facilities. The Spreading Healthcare Access, Activities, Research and Knowledge (SHAARK) QUERI will compare implementation strategies for EBPs in two areas of high relevance to VA: addressing the needs of veterans suffering from moral pain (e.g., guilt, shame, betrayal) as a result of actions taken or not taken during their service (aka, moral injury) and veterans who face the substantial health risks of persistently poor diabetes control. While these groups are important in-and-of themselves, the synergy that comes from studying implementation of distinct EBPs aimed at different complex health conditions will lead to a greater understanding of how to address the overarching implementation challenge of moving clinical EBPs across health systems. Significance/Impact: In alignment with VA facility and VISN Director Performance Plan metrics to identify and spread innovations, the SHAARK QUERI will provide evidence for how VA and other healthcare systems can use strategies for spreading complex clinical EBPs beyond successful earlier adopters across the healthcare system. This evidence will be obtained by conducting clinical trials of an implementation strategy aligning with the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation framework, while specifically seeking to improve care for moral injury and persistently uncontrolled diabetes. Specific Aims: Using two EBPs, Advanced Comprehensive Diabetes Care (ACDC) and Moral Injury Groups, we will conduct two hybrid type 3 implementation trials that align with the EPIS framework for the establishment of strategies to implement EBPs. The specific aims are as follows: Aim 1a: Measure difference in the percentage of patients receiving appropriate dose/adherence to group attendance (attending ≥ 80% of group sessions) as an indication of fidelity; Aim 1b: Measure differences in the percentage of core components implemented and number of adaptations to EBP processes; Aim 1c: Examine differences in the number and intensity of quality improvement efforts/plan-do-study-act cycles undertaken by sites; Aim 2: Examine differences in change in PTSD symptoms, suicidal behavior, & perceived life significance (for Moral Injury Groups trial) and difference in change in hemoglobin A1c (for ACDC trial); Aim 3: Conduct evaluation of implementation process; and Aim 4: Build a business case including budget impact (for both EBP trials). Methods: We will test the implementation strategy, Dynamic Diffusion Network (DDN), for operationalizing EPIS (1 separate DDN per trial) for later adopters of EBPs. The DDN will be compared to technical assistance. For each trial, 10 VA facilities will be randomized to implement the EBP using either the Dynamic Diffusion Network EPIS implementation strategy (5 sites) or technical assistance (5 sites). Primary outcomes will be focused on successful implementation of the EBPs, use of EBP components, and rapid improvement processes, as well as secondary clinical outcomes of the practice. Program materials previously used for both EBPs will be refined into an initial change package/implementation toolkit to be shared with each interested site. The toolkits will be assessed by two frontline staff members who have had previous experience implementing the EBPs. We will also conduct a formative evaluation of both EBPs to explore factors potentially influencing outcomes at each EPIS stage based on the Consolidated Framework for Implementation Research (CFIR). The evaluation will use a mixed methods approach consisting of semi-structured, qualitative interviews, surveys and other complementary methods with participating VA sites. A business case will be developed based on a balanced scorecard approach, accounting for outcomes, cost, and implementation.