In 2016, the Precision Monitoring (PRIS-M) QUERI (Quality Enhancement Research Initiative) based at the Roudebush VA Medical Center in Indianapolis, Indiana was charged with supporting and studying the implementation of the VHA Tele-Stroke Robotic Rehabilitation program at four pilot sites around the United States. The 7-person implementation team based in Indianapolis included three doctoral-level implementation scientists who collectively had been working in implementation science for over 30 years in VHA, a senior physician-researcher, a masters-level program manager, and a research assistant.
As part of this work, the implementation support team developed general specifications of a new “State of Implementation” Progress Report (SIPREP) over a 6-month period in 2018. They drew upon multiple sources of information to map the implementation work: weekly national program phone calls, discussions with individual participants, site visits, notes from implementation team meetings, and online resources. Stage-specific grids organized the implementation work into columns, rows and cells, identifying specific implementation activities to be completed; who was responsible for completing each implementation activity; and the timing/level of each activity (early/basic, intermediate or late/advanced). Additional links provided access to specific tips and resources that could assist local staff in completing particular implementation activities.
The SIPREP was subsequently applied independently by two different teams working on two different and unrelated national VHA QI initiatives. The first initiative was the Tele-Stroke Robotic Rehabilitation program based at the Atlanta VA Medical Center. The Tele-Stroke Robotic Rehabilitation program provided rural Veterans recovering from a stroke with an innovative, in-home solution for physical rehabilitation that especially benefited Veterans living in rural areas distant from Veterans Health Administration medical centers. The program was a quality improvement (QI) project funded by the VA Office of Rural Health as an Innovations Project to be implemented at four pilot sites.
In FY17, the PRIS-M implementation support team assisted the Atlanta-based clinical team with implementation of the program, and was specifically charged with providing ongoing feedback to the Tele-Stroke Robotic Rehabilitation program about implementation progress at the participating sites as well as providing guidance for any future scaling up of the program if it received approval for a larger rollout. With these aims in mind, the team developed the new “State of Implementation” Progress Report (SIPREP) approach.
Each of the four participating VA medical centers was given its own designated grid for each stage of implementation. Within each grid, item-level checkboxes were checked off and cells changed colors as particular activities were completed, offering a visual representation of implementation progress within and across sites across the various stages of implementation. The SIPREP was hosted on a VA SharePoint platform, and the implementation support team created, maintained and updated the SIPREP for all four VA medical centers.
Two key concepts used to organize the SIPREP were “milestones” and “stages.” Milestones were significant implementation achievements that occurred in a chronological order. In the implementation of the Tele-robotics program, there were five milestones: Initial Agreement to Participate; Kickoff; Enrolling 1st Patient; Enrolling 10th Patient; and Adoption/Sustaining. Stages involved from getting from one milestone to the next.
Stage-specific “grids” organized the implementation work into columns, rows and cells, identifying specific implementation activities to be completed; who was responsible for completing each implementation activity; and the timing and level of each activity. Grid columns specifying who completed particular implementation activities, and grid rows indicated the timing/level of each activity.
Additional links provided access to specific tips and resources that could assist local staff in completing particular implementation activities.
Each of the four participating VA medical centers was given its own designated grid for each stage of implementation. Within each grid, item-level checkboxes were checked off and cells changed colors as particular activities were completed, offering a visual representation of implementation progress within and across sites across the various stages of implementation.
A different implementation support team located in a different part of the United States independently applied the SIPREP to evaluate implementation progress on another national VHA program. The PeRsonalizing Options for Veteran Engagement (PROVE) QUERI program based at the VA Ann Arbor Healthcare System began using the SIPREP as part of implementing and evaluating a web-based, provider-facing tool for enhancing shared-decision making with patients eligible for lung cancer screening.
The Lung Decision Precision (LDP) tool was initially implemented using a six-month, virtual quality improvement training approach in four VA medical centers beginning in 2017. Four other VA medical centers served as a control group, in which the tool was implemented using a one-time provider education approach.
In 2018, midway through implementation of LDP across the eight participating sites, the PROVE QUERI lead investigator learned about the SIPREP from a VHA webinar series and discussed potential use of the tool with the project manager in charge of the LDP implementation. The eight participating sites were all progressing with implementation at different rates, and had implemented lung cancer screening in different ways, which affected their interest in and ability to use LDP. As a result, it was challenging for the national team in Ann Arbor to keep track of implementation progress at individual sites. The lead investigator thought the SIPREP would be an apt mechanism for capturing the status of implementation at each site and clearly delineating next steps.