Improving performance through knowledge translation in the Veterans Health Administration.

The Veterans Health Administration (VA) provides a case study for linking performance measurement, information technology, and aligned research efforts to facilitate quality improvement in a large, complex health system. Dialogue between clinical researchers and VA leaders occurs through structured activities (e.g., the Quality Enhancement Research Initiative); engagement with formal policymaking bodies (e.g., development of clinical guidelines and performance measures); and informally through local, regional, and national work groups responsible for implementing evidence-based clinical initiatives. Important lessons for knowledge translation from the VA experience include the following: research needs to generate clinical evidence relevant to the needs of patients served by the health system; researchers need to systematically study the process of evidence implementation itself to increase the capability of the health system to improve performance; although print and Web-based dissemination structures are important, direct accessibility of researchers to policymakers and clinical leaders through formal and informal mechanisms is key; and both top-down and bottom-up activities are needed to integrate evidence-based practice across a large health system. As VA care moves from hospital and clinic into community-based settings and faces a new veteran population with different needs and expectations, knowledge-translation activities must develop new forms of evidence and more direct interaction with veterans and their caregivers.