Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative.

OBJECTIVE: The Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care. METHODS: In the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance-the Colorectal Cancer Care Collaborative (C4). RESULTS: We describe the process and thinking that led to two parallel quality improvement "collaboratives" that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions. CONCLUSION: We conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Using a framework for spread: The case of patient access in the Veterans Health Administration.

BACKGROUND: Experience indicates that an effective operational system will spread much more slowly than, for example, a new antinausea drug. The Veterans Health Administration (VHA) used a Framework for Spread to spread improvements in access to more than 1800 outpatient clinics between April 2001 and December 2003. The framework identifies strategies and methods for planning and guiding the spread of new ideas or new operational systems, including the responsibilities of leadership, packaging the new ideas, communication, strengthening the social system, measurement and feedback, and knowledge management. APPLYING THE FRAMEWORK FOR SPREAD: Following a collaborative for reducing waiting times for patients without the large-scale addition of resources, each of the participating 22 Veterans Integrated Service Networks (VISNs) used the framework to expand improvements in access to care to six additional targeted clinics (for example, primary care, eye care, cardiology). RESULTS: During the VHAs spread initiative, waiting time for a primary care appointment decreased from 60.4 days at the end of fiscal year (FY) 2000 to 28.4 at the end of FY 2002. Results were sustained. Waiting time was <25 days at the end of FY 2004. DISCUSSION: The Framework for Spread suggests areas that organizations should consider when developing and executing a strategy for a spread initiative. Further study is needed to determine the specific activities that should be emphasized to accelerate spread.