Table 1 Summary and description of expanded six-step QUERI process model

Step 1: Select conditions per patient populations associated with high risk of disease and/or disability and/or burden of illness for veterans

1A. Identify and prioritize (via a formal ranking procedure)

1B. Identify high-priority clinical practices and outcomes within a selected condition

▪ Overall conditions addressed by QUERI Coordinating Centers are selected by the VHA [Veterans Health Administration; also referred to as VA in this Series] and national QUERI leadership. QUERI Center Executive Committee then assigns priorities to specific sub-topics within each clinical area selected to provide the greatest possible impact on veteran health.

▪ QUERI groups seek opportunities for collaboration on overlapping priorities, such as relevant coexisting diagnoses (e.g., mental illness and substance use disorder).

▪ Epidemiological and outcomes studies may be conducted or, if available, used to facilitate decision making.

Step 2: Identify evidence-based guidelines, recommendations and best practices

2A. Identify evidence-based clinical practice guidelines

2B. Identify evidence-based clinical recommendations

2C. Identify evidence-based clinical practices

▪ Can include systematic reviews and/or a consensus process

Step 3: Measure and diagnose quality and performance gaps

3A. Measure existing practice patterns and outcomes across VA and identify variations from evidence-based practices ("quality/performance gaps")

3B. Identify determinants of current practices

3C. Diagnose quality/performance gaps

3D. Identify barriers and facilitators to improvement

▪ Includes variations studies to a) measure care processes related to clinical conditions and related deviations from best practices, and b) explain various influences on practices.

▪ Studies focus on general, VA-wide gaps relative to a targeted condition or issue.

Step 4: Implement improvement programs

4A. Identify improvement/implementation strategies, programs and program components or tools

4B. Develop or adapt improvement/implementation strategies, programs and program components or tools

4C. Implement improvement/implementation strategies/programs to address quality gaps

▪ Requires literature searches for evidence-based implementation interventions, change strategies and related tools.

▪ Includes development and evaluation of implementation or practice support toolkits, such as educational materials or clinical reminder content.

▪ Researchers expected to consider relevant methodological approaches, e.g., a conceptual framework, an appropriate study design and facilitation [11].

Step 5/6: Evaluate improvement programs

5. Assess improvement program feasibility, implementation and impacts on patient, family and healthcare system processes and outcomes

6. Assess improvement program impacts on health related quality of life (HRQOL)

▪ Should consider both formative and summative evaluation.

▪ As part of formative evaluation [FE], would include a developmental-stage local diagnostic analysis to affirm generically identified barriers in study sites; would also consider other FE stages [9].

▪ Should consider a cost- or business case analysis.

SUPPLEMENTAL RESEARCH ACTIVITIES

Step M: Develop measures, methods and data resources

M1. Develop, refine and validate patient registries and databases documenting healthcare organizational features, clinical practices and utilization, and outcomes.

M2. Develop and/or evaluate case-finding and screening tools.

M3. Develop and/or evaluate measures of healthcare structures, processes and outcomes.

Step C: Develop clinical evidence

C1. Develop and evaluate evidence-based clinical practices and recommendations (clinical research).

C2. Develop and evaluate evidence-based health services interventions (health services research).

▪ Step M and C projects are considered to be outside the core QUERI process, although they support implementation research. Such projects are generally funded through regular VHA or external clinical science and health services research funding programs.