Writing a “Quality” Manuscript Virginia A. Moyer, MD, MPH Deputy Editor

Why write about your work? Forces you to clarify your thinking, verify your observations, and justify your inferences. Hastens the spread of important and useful innovations. Reduces the waste scarce of resources in confirming findings that are already firmly established. Makes it possible to confirm uncertain findings.

Why write about your work? Keeps people from repeating mistakes unnecessarily. Contributes to the “collective memory,” which provides the context for interpreting new findings properly. Returns something of value for the time, effort, inconvenience, and funds that people put into the work. Holds you publicly accountable for your efforts.

Why publish on QI? “Failure to publish is potentially a serious barrier to the development of improvement in health and medical care and improvement science generally…” –Davidoff et al

What’s different about QI reporting? “Pragmatic science” vs. traditional experimental clinical science –Sometimes at cross purposes –Can it work? vs. How, for whom, and under what circumstances does it work? Improvement is a social process whose purpose is to change human performance Experiential learning –Rapid cycle change means that interventions are not static Highly context-dependent

Reporting on QI is inadequate Paucity of descriptive detail regarding interventions Lack of detail for other elements Some elements missing entirely

SQUIRE to the rescue!

Reporting Guidelines “STREGA, STROBE, STARD, SQUIRE, MOOSE, PRISMA, GNOSIS, TREND, ORION, COREQ, QUOROM, REMARK… and CONSORT: for whom does the guideline toll?” Jan P. Vandenbroucke Journal of Clinical Epidemiology 2009;62(6): Journal of Clinical Epidemiology

SQUIRE SS tandards for QUQU ality II mprovement R eporting EE xcellence

Purpose of SQUIRE The SQUIRE Guidelines help authors write excellent, usable articles about quality improvement in healthcare so that findings may be easily discovered and widely disseminated.

SQUIRE First proposed in 2005 Informal feedback and road- testing EQUATOR feedback Published commentary Formal, funded analysis and refinement in 2007

Essential elements of SQUIRE: IMRaD Why did you start? What did you do? What did you find? What does it mean?

Essential elements (IMRaD) Why did you start? (Introduction) –Background, local problem, intended improvement, study question What did you do? (Methods) –Ethical issues, setting, planning the intervention, planning the study of the intervention, evaluation methods, analysis plan

Essential elements What did you find? (Results) –The course of the intervention, how it evolved and degree of success in implementation, data on changes in process and outcomes, problems and failures What does it mean? (Discussion) –Summary, relation to other evidence, limitations, interpretation, conclusions

When should you use SQUIRE? To describe theories and frameworks for QI To describe QI reviews and syntheses To describe development and testing of improvement-related tools To describe development and testing of QI interventions

Concerns and limitations Does SQUIRE force QI reporting into a rigid format? –“signposts, not shackles” Will articles be too long? –Use data supplements and electronic indexes Can SQUIRE be used with other reporting guidelines? –Can be complementary Will editors insist on a checklist and reject papers that don’t include all elements? –Not likely – very few journals even do this with CONSORT

How to use SQUIRE “SQUIRE is most helpful if authors simply keep the general content of the guideline items in mind as they write their initial drafts, then refer to the details of idividual items as they critically appraise what they have written during the revision process.”

Apply the Guidelines Group 1: Introduction and Methods Group 2: Results Group 3: Discussion/Conclusions

Which journals use SQUIRE? American Journal of Critical Care (AJCC) American Journal of Nursing Annals of Internal Medicine British Medical Journal Canadian Journal of Diabetes Clinical Journal of Oncology Nursing Joint Commission Journal on Quality and Patient Safety Journal of General Internal Medicine Journal of Nursing Care Quality Quality and Safety in Health Care Spine AND soon (!):

Where can I learn more? (a lot more…) SQUIRE guidelines in pdf –long and short form SQUIRE Explanation and Elaboration (E&E) –6 main areas (IMRaD), 19 items, and 44 sub- and sub-sub-items ALL explained in detail(!) –With real examples from the literature Excellent grand rounds on SQUIRE

“What you publish is associated with your name forever…Make it the best quality possible.” George Lister, MD

Writing is easy. All you do is stare at a blank sheet of paper until drops of blood form on your forehead. --- Gene Fowler