Business not as usual: Implementation Strategies that Support Learning during the COVID-19 Pandemic

Cross, Dori A.; Pestka, Deborah L.; White, Katie M.; Shah, Surbhi

Health system response to COVID-19 required drastic care delivery changes, but also a substantially altered environment in which to observe implementation of more standard quality improvement efforts. Implementation assessment during disrupted operational norms (“business not as usual”) distills challenges solved by prioritization from those requiring solutions that address more fundamental barriers to change. This commentary retrospectively analyzes health system implementation of a clinical practice guideline intended to support COVID-19 treatment. We use the QUERI roadmap to reflect upon implementation strategy within the context of a nascent LHS framework. In doing so, we identify aspects of implementation that were facilitated by the COVID-19-altered environment, enduring implementation challenges with respect to fidelity and sustainability, and key areas of necessary continued investment to strengthen a responsive system for learning and improvement. Moving forward, COVID-19 response highlighted key investments that bridge learning health system structures to implementation practices. This includes structures that (1) accelerate ideas that emerge from the front lines, (2) promote “living” care guidelines that are supported by continuous review of emergent evidence, and (3) enhance analytic capacity that supports organizational learning. COVID-19 response has offered opportunities for “new norm” thinking around what’s possible to build out a learning health system. Strategic application of implementation frameworks to learning health system infrastructure has highlighted necessary investments that build and sustain a more responsive, improvement-oriented organization.