In 2012, after completing her medical training at George Washington University, Jessica Logan, MD, FACP, was selected to be a chief resident for quality and safety at the Washington, D.C., Veterans Affairs Medical Center (VAMC). The chief resident program, started by Veterans Affairs (VA) in 2008, annually trains 110 resident physicians across 60 VAMC sites in the skills of quality-improvement research and dissemination.
Dr. Logan
Qualified applicants demonstrate a strong commitment to quality improvement (QI) and patient safety. The experience and training impart the knowledge, skills, and attitudes necessary to become future leaders in QI, said Dr. Logan, now associate section chief of hospital medicine at the VAMC and assistant professor of medicine at George Washington University, both in Washington, D.C. She counts herself an advocate.
The VAMC currently has two chief residents for quality and safety, and she is one of their mentors. “They are doing tremendous work, and it really helps us with recruitment and retention. It’s an amazing program and helps build the culture of quality in the VA, identifying the people who will do the work of QI.” Participants spend part of their year on a capstone project, which they present to local and regional Veterans Integrated Service Network (VISN) leadership.
Other academic medicine settings with chief residents could learn from the VA’s experience, building similar programs to train and retain physicians adept in QI, thereby creating a pipeline of future QI experts for conducting high-quality projects, Dr. Logan said.
The Veterans Health Administration (VHA) is among the nation’s largest integrated health systems, with a commitment to being a learning health system, and with measurement science at the core of its learning. VHA is known for supporting medical research and for focusing research on quality improvements that can be disseminated systemwide. It has also made a significant commitment to supporting researchers, with an emphasis on collaboration across sites and disciplines. And it has been shown, in several comparative studies in different areas (for example, cardiac care1), to outperform non-VA hospitals in patient satisfaction and hospital quality ratings.
Varied Quality Initiatives
VA’s QI initiatives, in addition to the chief resident, include the Quality Enhancement Research Institute (QUERI) in the VA’s office of research and development, established in 1998.2 QUERI funds VA investigators across the country to work with key stakeholders in transforming the care delivered to veterans. It leverages scientifically supported QI methods, paired with a deep understanding of veterans’ preferences and needs, to rapidly implement evidence-based practices into routine care.
While QUERI doesn’t have a hospital medicine-specific research agenda, it does fund and support significant research relevant to hospitalists. It emphasizes small-scale quality projects, but also plans for how they can be successfully disseminated to other VAMCs and sustained over time. The QUERI Implementation Roadmap aims to demystify the application of new implementation strategies to help clinicians overcome common barriers to adoption.
Quality-scholar fellowships at 11 VA sites are designed to train the next generation of health professionals to improve healthcare through innovative QI and patient safety projects. This two-year interprofessional fellowship uses a broad curriculum and individualized approaches for doctoral and post-doc nurses and doctors of nursing practice (DNPs), psychologists, pharmacists, physical therapists, and physicians who are completing their residency and have an interest in quality or implementation research.
The fellowship offers paid full-time experiences in QI and patient safety, with opportunities to meet and collaborate with other physicians across the country. All fellows are paired with a primary mentor, participate in a site-based curriculum, and enjoy 75% protected time for research and education.
Other examples of the VA’s involvement in quality initiatives include:
- National Center for Patient Safety, which has promoted best practices for safe patient care and optimal utilization throughout the organization since 1999, guiding VHA and external stakeholders on policies and strategies to measure and mitigate harm to veterans and to those who support their care, modeling characteristics of a high-reliability organization
- VA Centers of Excellence, a network of specialized programs, some focusing on a single disease, with comprehensive services at designated VA facilities for veterans seeking the highest quality of care for specific conditions
- VA’s national hospital medicine program, which provides a national framework within the VA to standardize and improve inpatient care for veterans, drawing upon 18 national hospital medicine consultants, based at each VHA VISN, to guide network chiefs to solve problems and share best practices
- The Diffusion Marketplace, a collaborative tool that curates promising clinical, operational, and strategic innovations in the VA, and the annual Shark Tank Competition, which identifies the best innovations in QI from all the VAMCs across the country and then helps to disseminate them
- Hospital Medicine Analytics Team (HMAT), established to improve overall care of hospitalized patients in the VA, starting with creating a data infrastructure to help identify problems that need to be fixed
Med Rec and ED Throughput
Dr. Logan’s chief resident for quality and safety capstone project, whose results were published in the Journal of Graduate Medical Education,3 assessed an educational intervention focused on QI principles and effective medication reconciliation techniques for internal medicine residents. The accuracy of discharge medication instructions was compared before and after the intervention. Improvements were shown in lower rates of duplicate medications, extraneous medications, and discrepancies between discharge instructions and summaries.
After completing her chief resident year, Dr. Logan joined the hospitalist faculty at the Washington, D.C., VAMC. She is also associate chief of the VA’s national hospitalist section. At the VAMC, the hospitalist group’s quality work focuses on department-based projects, borne out of self-reflection and a desire to address frustrations clinicians sometimes feel in their practice, Dr. Logan said. “But we also join facility-wide initiatives involving interdisciplinary teams, which are supported by the medical center.”
The QI model they most commonly use is the plan, do, study, act (PDSA) approach taught by the Institute for Healthcare Improvement.4 It breaks down tasks into discrete steps, evaluates outcomes in terms of improvements, and then tests again. The VA also likes Lean management philosophy and offers Lean certifications at various levels, Dr. Logan said.5 “I’ve gone on to earn a Lean Yellow Belt. But I prefer PDSA. Training in PDSA methodology is widely available.”
One major topic area Washington VAMC hospitalists have been pursuing involves throughput times in the emergency room, a major concern for many emergency departments. This multidisciplinary project uses rapid process improvement groups, regular meetings, and specified target dates for deliverables.
For instance, the team learned that there weren’t enough inpatient telemetry boxes to meet patient demand from the emergency room. Many of these patients were getting mis-triaged. Overuse of telemetry can result in delays in care and wasted health care dollars, Dr. Logan said.6 “We performed a gap analysis and spun out improvement projects led by other members of the hospitalist group.” They created an order set for the optimal use of telemetry drawn from American Heart Association telemetry guidelines, which led to further improvement projects.
But so far, the initiative has produced mixed results, Dr. Logan said. There can be a tendency for clinicians not to follow the order set, even though it was derived from American Heart Association guidelines with triggers incorporated into the electronic health record. “Trainees and other clinicians get nervous (about patient outcomes) and don’t want to go by the guidelines. In practice, a cultural shift is needed, but cultural change is hard. That is why systems changes beyond the individual are stronger QI interventions,” she said.
“Even though they say education is a lower yield in QI, we still do a lot of education,” said Monee Amin, MD, a hospitalist affiliated with the Atlanta VAMC and assistant professor of medicine at Emory University Medical School. QI has to be role-modeled by the faculty, she added. “And repetition is key. The more you provide it, the more it sticks. And making the electronic health record accessible and easy for people to use.”
Dr. Amin
Dr. Amin’s group has worked on building order sets that do not require a lot of thought to follow. “Having things pre-populated and put right in front of providers helps.” Her group also convenes a monthly virtual Faculty Patient Safety Conference. “That was something I spearheaded because we needed a forum for talking about important issues. I also mentor our chief resident to make presentations to the faculty, with ample opportunity for discussion of their topics.”
Dr. Amin returned to work at the VA six years ago, although she still teaches residents and medical students at Emory in QI and patient safety. “My focus was on the triage process for a very high-volume walk-in clinic, coming up with criteria for triaging people.” That includes guideline-directed medical therapy for heart failure at hospital discharge.
Working on Readmissions, Medications
For Jeydith Gutierrez, MD, MPH, clinical associate professor of internal medicine-hospital medicine at the University of Iowa and founding director of the tele-hospitalist service at the Iowa City VAMC, her experience with QI reflects a large degree of partnering between VA and academic medical centers.
Dr. Gutierrez
“Through my time at the VA, I have worked on several quality improvement initiatives. One of the first was called the Transitions of Care Clinic, a program we established at the Iowa City VAMC to do follow-ups soon after patients were discharged home from the hospital,” she said.
“We know there has been a lot of emphasis on preventing readmissions within 30 days after discharge. Not all readmissions are preventable, you know, but some are.” Often, those that are preventable are due to things like medication mismanagement, where the patient didn’t take the right medications when they were discharged home, or maybe didn’t pick them up at the pharmacy, or something else that might have been missed on discharge.
The researchers found that for patients who had certain conditions or other factors associated with readmissions, their readmission rates were reduced by having this type of close follow-up after discharge by the hospitalist group—virtually or in person, depending on how far away the patient lived—in collaboration with outpatient clinics.
Another QI project at the Iowa City VAMC, with perhaps the biggest impact to date, involves how alcohol withdrawal—a major cause of morbidity in the veteran population—is treated in the inpatient setting. Order sets for inpatient alcohol treatment are normally developed locally and can be highly variable between medical centers. In some cases, those protocols haven’t been revised for years, despite advances in national guidelines.
“I was involved in a project to help our rural VAMCs that we work with through our tele-hospitalist program,” Dr. Gutierrez said. She connects with many VA hospitals and was able to review their policies and order sets in order to improve processes of care to make them consistent with the most updated clinical practice guidelines from the American Society of Addiction Medicine.
“We developed a comprehensive quality improvement initiative to look at these processes of care, when existing policies were written, whether providers and staff were trained in how to identify patients that were at risk, and how to score patients in their system’s withdrawal scale. We also look at treatment protocols and incorporation of medications to treat alcohol use disorder and referral to substance use treatment programs on discharge,” Dr. Gutierrez said.
“We started in a small rural VA hospital that I was working with, but it evolved into a bigger national initiative across the VA.” A multidisciplinary National Alcohol Withdrawal Syndrome inpatient workgroup was convened and sponsored by the National Hospital Medicine Program Office in conjunction with the National Mental Health Program Office.
The experts produced guidance and specific recommendations about what should be standardized or tailored to the specific local resources, and then developed a notice instructing all VA hospitals in the country to review their treatment of alcohol withdrawal and improve the care of veterans, she explained.
This is an example of how the VHA invests in providing seed funding and other financial resources to make these projects happen. “A lot of our funding has come from the Office of Rural Health, but there is also health services research funding, along with other initiatives like QUERI, which issues calls for grant proposals, and has really made it possible to have people who are dedicated and committed to do the work. Otherwise, it’s difficult to make QI projects happen.”
Relentless Pursuit of Measurement
For Robert Burke, MD, MS, a hospitalist clinician with the VA in Philadelphia since 2011 and a core investigator with the Center for Healthcare Evaluation, Research, and Promotion, the VA embodies a relentless pursuit of measuring and improving quality of care. This center is a VA Health Systems Research Scientific Center of Innovation dedicated to understanding and improving health and healthcare outcomes to support the VA in providing excellent care and service to all veterans.
Dr. Burke
“One of the nice things about this health system is that it’s national, using the same electronic medical record, with many similarities in terms of staffing and processes,” he said. If you can execute a good quality improvement project in one place, it’s a lot easier to spread it to more places in the VA than might be possible in the private sector.
Dr. Burke reflected on the VA’s philosophy about quality improvement. “It’s hard to do high-quality, rigorous QI without institutional support. Funding allows people not to have to do QI on their nights and weekends, and allows improved access to data and analytic resources.” The VA has dedicated financial support through the mechanism of QUERI, among others. “They fund a variety of different types of projects. You can partner with hospital administrators, with operations leaders, even across VA VISNs,” he said.
“You might not be a full-time QI researcher, but if you have a position at the VA, you will be encouraged to apply what you’ve learned.” Projects vary in size and funding. The mechanism might provide two years of funding to start up in a small number of sites, he said. “And then there might be a second phase that is much larger, spreading it to 20, 30, or 40 sites.”
Currently, Dr. Burke spends a lot of his work time writing grants and pursuing health services and health policy research projects, much of that within the VA system. “We are trying to implement evidence-based practice that improves care at the bedside at scale. It’s easier to do things at scale in the VA. One of the projects I’m working on now is implementing four different evidence-based practices at nine VA medical centers, all related to the care of older adults in the hospital.”
Dr. Burke runs one of the VA’s QUERI Program Centers with colleagues in the Philadelphia area, with a focus over the next five years on implementing evidence-based, age-friendly practices in the hospital for older adults. One of its goals is to reduce veterans’ need for nursing home care. There are 8,000 patients enrolled in the study, the first large-scale randomized trial implementing age-friendly, evidence-based practices, he said.
Called SAGE—Safer Aging Through Geriatrics-Informed Evidence-Based Practices—in its first iteration, it attempted to implement four evidence-based practices aligned with the Age-Friendly Health System model. That is one practice for each of the Four Ms of age-friendly care: what matters to the patient, medications, mobility, and mentation.
“For example, for medications, we did an intervention to help people stop taking potentially harmful medications—a deprescribing intervention. For what matters, we identified people who were going into surgery who were frail and unlikely to do well from it. We had a conversation with them before they went into surgery to say, ‘This is what your outcomes might look like. We want to make sure that’s consistent with your goals.’” That process is also called the Surgical Pause, and it has been among the most successful age-friendly innovations to date.”
Hospitalists’ Role in QI
Dr. Burke described his own initial training in QI as “informal, as with many hospitalists. I wish I could say I have a badge that attests that I’m a QI expert. That would normally come from completing a fellowship. But like a lot of people, my QI training was small-scale and experiential, from IHI [the Institute for Healthcare Improvement] or Lean Six Sigma training,” he said.
“I practiced as a full-time bedside clinical hospitalist for four years after I finished residency. But then I decided I really wanted to try to impact the underlying policies and payments, and practices that affect a lot of veterans. So I went back and got a master’s degree in clinical research, to be able to become a researcher leading larger-scale projects,” he said.
“I could see some readers reacting to this article and saying, ‘Well, it’s all really nice that this investment in QI exists in the VA, but I don’t work in the VA.’ But I think there have been important efforts of a similar kind in the non-VA world to also do this kind of work.” The HOMERuN Collaborative’s multi-center hospitalist network is an example.
Dr. Burke noted that when QI first got started, there was a sense that most QI was local. “But I think the field has evolved, and now the focus is on what can be generalizable about QI. How can we spread successful QI initiatives as far and as effectively as possible?” he said.
Dr. Logan also believes that the culture of quality is strong in the VA. “That is shown in a number of ways: The chief resident program is one. Institutional leadership support for research initiatives is another. The VA is a repository of so much information, it’s easier to get the data you need to help you improve things,” she said.
Another helpful resource has been the VA’s Academic Hospitalist Listserv. “You can pose questions, and the response is just extraordinary. I’ve even seen offers from one institution to another, ‘We’ll lend you our IT expert for a one-hour consultation on Microsoft Teams.’”
“It’s clear that there is a desire to provide high-quality care in the VA,” Dr. Amin added. “We have a patient safety office with multiple officers. There is a culture of always trying to find opportunities to change and improve. At its best, the VA is a place where providers from multiple disciplines work together on projects— with a focus on making sure that all of the stakeholders are in the room.”
Larry Beresford is an Oakland, Calif.-based freelance medical journalist.
References
1. Le DE, et al. The quality of Veterans Healthcare administration cardiovascular care. JACC Adv. 2025;4(2):101533. doi: 10.1016/j.jacadv.2024.101533.
2. Garrido MM, Kilbourne AM. Evolution of the Veterans Health Administration learning health system: 25years of QUERI. Health Serv Res. 2024;59 Suppl 2(Suppl 2):e14372. doi: 10.1111/1475-6773.14372.
3. Arundel C, et al. Safe medication reconciliation: an intervention to improve residents’ medication reconciliation skills. J Grad Med Educ. 2015;7(3):407-11. doi: 10.4300/ JGME-D-14-00565.1.
4. Institute for Healthcare Improvement. Plan-Do-Study-Act (PDSA) worksheet. IHI website. https://www.ihi.org/library/tools/plan-do-study-act-pdsa-worksheet. Accessed October 7, 2025.
5. Lawal AK, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014;3:103. doi: 10.1186/2046-4053-3-103.
6. Pendharkar SS, et al. AHA telemetry guidelines improve telemetry utilization in the inpatient setting. Am J Manag Care. 2020;26(11):476-481. doi: 10.37765/ajmc.2020.88525.