Research & Services Partnerships: Lessons Learned Through a National Partnership Between Clinical Leaders and Researchers

Implementation of quality improvement initiatives in routine clinical settings is challenging. Implementation research experts and clinical leaders recognize that partnering with one another can foster buy-in, local fit, and long-term sustainability (1). Extensive literature exists on including clinical partners in research activities (2). There is also literature on how researchers work directly with clinical managers on tasks such as the evaluation of clinical initiatives and development of performance measures (3). Researchers and clinical operations managers in the U.S. Department of Veterans Affairs (VA) are engaging in another type of partnership, not yet well described in the literature. Specifically, researchers in this partnership serve as a resource of implementation knowledge for use in health care system change. This column describes lessons clinical operations managers and their research partners learned in this unique relationship.

Background

Clinical partners were operational managers in the VA Office of Mental Health Operations (OMHO). Established in 2011, OMHO’s mission is to ensure execution, monitoring, implementation, and integration of mental health policies within Veterans Integrated Service Networks (VISNs) and VA facilities. OMHO goals include ensuring quality of and access to mental health services, decreasing variability in mental health service delivery, developing and implementing operational practices in collaboration with VISNs and facilities, and managing national mental health operational programs. OMHO activities include developing informatics tools and reports, providing technical assistance and consultation, and disseminating strong practices.

Research partners were located in VA’s Mental Health Quality Enhancement Research Initiative (MH QUERI) center. QUERI is a national research program established in 1998 as part of the broader transformation of VA health care. MH QUERI’s mission is to improve the quality of care, outcomes, and health-related quality of life for veterans with mental health conditions by promoting research that closes gaps in knowledge and by implementing evidence-based practices. Further, MH QUERI seeks to promote bidirectional partnerships for the coproduction of research and knowledge exchange between investigators and stakeholders. Yet, as noted by a past director of QUERI, “Sometimes we are better at describing processes than fixing them, and we haven’t turned generalizable lessons from implementation research into actionable guidance for managers” (4).

Context

The partnership between OMHO and MH QUERI came about via a series of research and clinical initiatives. VA allocated Clinical Initiative Funds in 2007 to integrate mental health services in primary care settings (PC-MHI). Clinical and research partners in one VISN developed a unique strategy that incorporated facilitation of PC-MHI implementation at clinical sites (5). A QUERI-funded research study later confirmed the effectiveness of this implementation strategy.

On the basis of these early successes, OMHO invited MH QUERI to form a partnership to incorporate this facilitation strategy into OMHO efforts to support national implementation of PC-MHI. MH QUERI research partners were charged with training and mentoring OMHO technical assistants and other OMHO partners in skills and processes needed to facilitate systems change. Further, MH QUERI assisted with the development of facilitation programs, working directly with sites on the uptake of specific practices such as PC-MHI (6).

Lessons learned: “partnering pearls”

Clinical operations leaders and research partners reflected on their experiences, identified specific lessons they learned, and synthesized them into common themes. Below we describe and share their partnering pearls—lessons learned—about the necessary foundations for partnering, the importance of relationships, the need for regular communication, and the need to recognize and adapt to partners’ timelines and time constraints.

Build a foundation

Clinical and research partners identified foundational factors necessary for a successful partnership. First, partners should have mutual respect for and value each other. Partners can foster this by identifying and sharing expertise and assets they each bring to implementation efforts. A research partner noted, “Partners bring unique skills and knowledge to the partnership. It is critical for partners to be aware of each other’s strengths as well as limitations.” A clinical partner recommended that operational managers “Speak up . . . Researchers may already know what problems have been solved and what lessons have been learned. So before you solve a problem, ask your research partner if anyone else has successfully addressed the issue.” This partner also recommended, “Share resources. . . . Recognize what resources you have that can help your partners.” One partner may bring rich outcome data to the table while the other brings a keen awareness of the cultural climate necessary for implementation efforts to succeed. Partners can learn from each other. In fact, one clinical partner suggested that “partners mentor each other along the way.”

Second, before initiating a partnership, “It is important for all partners to clearly know who ultimately ‘owns’ the project,” a clinical partner observed. By establishing ownership, partners are able to identify how best to create a shared implementation plan, set timelines for progress, and initiate evaluation procedures to ensure that progress reports include the appropriate data for upper management to assess outcomes.

Third, a research partner felt it was important for researchers to realize that “your clinical partners may not speak your language, but it is imperative that you speak theirs” and that you should “tailor your approach to meet your partner’s needs.” The use of research “jargon” can quickly create a communication barrier that is difficult to overcome. In addition, it is important for researchers to understand that various clinical partners may need varying types of information to advance a program.

Finally, as another clinical partner noted, partnering “requires a commitment from clinical leadership and the research community.” Without this commitment, a partnership can have an exciting and promising start but be unable to produce the anticipated outcomes. Research partners must take the time to fully understand policy requirements and the political and administrative context and constraints that complicate policy implementation. Further, rather than control variables as they do in studies, research partners will need to embrace fluidity and flexibility. Likewise, clinical partners should take time to ask about the lessons researchers have learned from their own research as well as the literature.

Develop relationships

Many of the pearls focused on the importance of relationships. A clinical partner noted, “All organizations are built upon relationships. While implementation researchers and operations partners are focused upon improvement in policy implementation, there must be an ever present focus on building relationships between these partners.” In addition, this clinical partner noted, “Successful change relies heavily upon working alliances with numerous partners. If relationship building is overlooked, the likelihood of successful change occurring is decreased.” Partner relationships develop over time and require focused energy to establish and maintain.

To be successful, partners need to be aware of and address barriers. One clinical partner noted, “It is important to keep in mind the potential for conflicting priorities and demands. There may be other organizational factors, interpersonal dynamics, and other systemic factors influencing the partnerships. Be aware of and look out for potential contextual factors outside of your program. Sometimes these factors may not be evident but could be influencing the relationships. Actively seek to create partnership relationships that support an ongoing quality improvement process and can work through differences or challenges.”

Partners noted the need to establish the type of environment that supports identifying and addressing barriers. Partners should “assess the process and have the flexibility to revise a process if something is not working for any of the partners,” a clinical partner observed. Flexibility is also critical, because clinical partners’ “needs may change, and are frequently driven by factors that they cannot control,” as noted by the same clinical partner.

Communicate on a regular basis

Clinical and research partners agreed that establishing regular communication is important. “Ongoing, routine communication is key: never underestimate the power of quick, weekly huddles,” one research partner said. As noted by a clinical partner, these brief meetings “can be utilized to exchange information, ask for information or resources, follow up on progress of implementation, and identify newly arising barriers. Information from these brief meetings can be used in real time to redirect efforts to maintain the focus on shared priorities.” Communication beyond the brief weekly meeting was also identified as valuable. A clinical partner noted, “Taking scheduled, structured time on a regular basis, monthly or quarterly, to be in contact and talk about current relevant issues in an environment in which each partner provides a five-minute brief of their top priorities is useful for all. These meetings may also be utilized to talk about priorities and share what is coming to fruition. They also provide a forum for planning and feedback. Researchers do not know what clinical operations [managers] know, and clinical operations do not know what researchers know. Each brings a unique knowledge set about implementation to the table, thus making regular communications crucial for success. Keeping in mind, in clinical operations priorities change, often on a day-to-day basis. New research findings are also occurring regularly. Bottom line: communicate often, learn, and share.”

Address timelines and time constraints

Partners recognized that, as one clinical partner put it, “True change takes time.” “Partnering is a process not an event,” noted a research partner. Yet partners may not be operating on the same timeline. Research partners need to “recognize the tension between quality improvement and scientific rigor—clinical partners may need the best information available as opposed to that which is backed by a ‘p value less than .05,’ ” a research partner observed. A clinical partner noted, “Your research partner may be more helpful when working on long-range, strategic issues rather than on tactical or immediate concerns—for example, partnering with researchers regarding their insight on where health care is trending in three to five years and noting that changes in practice may be prudent. By partnering with research early on, researchers have the time to study the pending practice matters.”

In addition, research partners may need to adapt to the decreased availability of clinical partners who are focused on meeting operational deadlines. Research partners need to be flexible and willing to meet early or late in the day and make last-minute appointment changes that are likely to occur as urgent situations emerge for their clinical partners. Yet, checking in regularly with clinical partners is critical for implementation success. One research partner noted, “Honor your partner’s time and contribution.”

It is important for partners to agree on timelines early in the process and then monitor progress. Although one research partner reflected, “Hard deadlines may be difficult for some partners. Still, partners need set deadlines, provided on a regular basis, or they would not get anything done. Knowing what is expected is important but sometimes may not be attainable.”

Partners may need to alter timelines when reevaluating an implementation plan. Not every planned action will lead to good outcomes. As one research partner shared, “You should listen if your gut says, ‘It won’t work,’ as there is a strong possibility it won’t. Yet sometimes in order to enhance the partnership and to ultimately be successful, you may have to engage in a process that you are doubtful will work.”

Conclusions

Mitchell and colleagues (2) argued that it was important to explore diverse models of partnering. VA researchers and clinical operations managers have formed a unique partnership, one that allows researchers to turn generalizable lessons from implementation science into actionable guidance for clinical managers to use in national health care system change. In this column, we describe and share lessons that VA partners have learned. Our experiences confirmed that although it is challenging to establish successful partnerships, such relationships are valuable and can facilitate the transfer of implementation science knowledge to decision makers. One research partner noted, “Partnering holds the promise of developing the processes and knowledge transfer necessary for successful quality improvement efforts.” Our hope is that our experiences will provide guidance for others who also engage in partnering relationships.