Welcome to the SQUIRE blogs, in which invited authors share their reflections on writing about their quality and safety work. These blogs are not a preview of that work and will contain little or no text or data from the authors' manuscripts. Rather, they provide an opportunity for authors to share their experiences with the process of writing, particularly the ways they use the SQUIRE guidelines, what's helpful about them, and what isn't.
I've now had 2 opportunities to present my experience using SQUIRE as part of a presentation with Greg Ogrinc. He gives the basic overview of how and why SQUIRE was created, and I get to talk about actually using the guidelines as I work to write up my quality improvement work in hand hygiene.
The audiences were different. In August we presented at Dept of Medicine grand rounds to what I would have characterized going in as a somewhat skeptical audience. The words "Quality Improvement" don't necessarily bring the words "academic rigor" to many people's minds. My sense, though, was that seeing the peer review process that went into developing the guidelines, and the prestige of the people involved, and the journal editors that have endorsed them spoke to some of the more traditional academics in the audience. The real-life example of turning messy QI work into a publishable work I think appealed to those in the audience who have tried to improve their work (as required by the ABIM) and were prompted to see the work as potentially an academic "product." Several people came up to me afterwards and said they had been inspired to pull out such projects and use the guidelines to try to make sense of them in this way.
The second audience was a group of MPH students at the Dartmouth Institute for Health Policy and Clinical Practice. They are learning how to improve healthcare, and probably already "drinking the koolaid." They asked great questions like "How do you know when in a project to start writing?" or "How do you separate out the improvement related to your interventions from the larger context of people improving healthcare (as we hope everyone at our medical center is doing)?" I'm not sure I had answers but it seems to me that the latter question really gets at the need to measure how well you implement your intended interventions, and the need to embrace variation in order to understand what works where and why.
Presenting again today is inspiring me to get back on the horse and try to get this manuscript finished before the end of 2009. I've been letting other things get in the way of finding the "writing space" in my life: like H1N1, and figuring out how to brine a turkey. I'll be getting back to blogging as I turn again to my manuscript for what I hope will be the final leg of this journey. Maybe the next version of the SQUIRE guidelines should include a suggested timeline for completion--something less than 5 years maybe!
My office is a little quirky. We have two distinct microsystems that inhabit the same space. A really small space, I might add. Two OB MDs and three Certified Nurse Midwives see obstetrics patients in the same building at the same time, yet they function as separate practices. Same manager and support staff but a different practice style that stems from philosophy. Our midwives believe in a true midwifery model. They believe that we, as a society, have medicalized pregnancy. Their primary mission as care providers is to provide education, support and comfort. They focus on wellness and relationships. They spend a lot of time with patients - an hour at the initial visit and then 1/2 hour each subsequent prenatal visit. They labor sit. They are firmly committed to quality patient care.
And yet, when I look at the data from the urine culture project, I am perplexed. The MD service has shown clear and steady improvement in both obtaining and documenting urine culture results. The CNM service - not so much. Every time I start to think we are making progress, we backslide. I have thought a lot about this. Sometimes, I think I understand what is going on in my office and other times I am baffled. All of the interventions have been the same for both services. Many of the support staff are the same. But, the processes that we introduce morph when the CNMs get ahold of them. And they morph in a way that negates the effectiveness. For example, the CNMs don't use the check-out form that the Docs love. They prefer to just tell the order to their support person who begins to drown in a barrage of verbal orders. We point this out to the CNMS. They nod and say they get it. They keep right on doing it. We talk about quality and ethics. They agree with me. They keep right on doing what they were doing before. It goes on and on.
I really want to understand what is going on but feel as though I am unable to do so. Perhaps we do not share a common definition of quality. Maybe the focus of the CNMs is on other things that they believe to be more important. Perhaps they see the use of standard checkout forms as less personal, less friendly and unnecessary. Direct, polite, verbal communication feels so much more human. And yet, a harried support person who is hearing 15 different verbal orders in 15 minutes is bound to make mistakes. She becomes flustered, stressed and is set up to fail. She makes mistakes. The system is unreliable. At the end of the day, I am frustrated with myself that I have been unable to solve this puzzle. Perhaps I have been too rational. Presenting data is clearly not the right tactic. I need to shift gears. Somehow, I need to make these issues resonate on a emotional level. I have no idea how to do that...
As I work through this project, I am beginning to think that the real story lies in understanding the difference between the MD and the Midwifery cultures. There is a lesson to be learned about designing interventions that respect those cultures and work with, rather than against, them. What works for the medical model that I know so well has faltered in the face of a different mental model of care. I need to understand this better if I have any hope of achieving meaningful change.
For the past few weeks I have been unable to do much in the way of writing. I have been thinking about my project - although it is a humble endeavor, it has made a difference in my clinic. I am confident that we now routinely and reliably collect 1st trimester urine cultures on more than 90% of the women who present for prenatal care. Part of me wants to shrug and say "about time" while another part of me knows that other places are just as deficient as we were. This is one of those tests that is so basic and so well accepted that everyone just assumes it is getting done. I bet no one really ever checks to see if their processes are working. I doubt that many facilities know their rate of 1st trimester urine culture screening.
Here's where I am - I know that I have identified and addressed a problem in my local environment. I suspect that other places have similar issues but I can't prove it. Further, I am betting that most people would just assume that they are getting this test done; therefore, my work will have no relevance to them. Which brings me around to the issue of generalizability. What have I learned that others don't know? What transcends my clinic? At its heart, this is a basic QI project that included all of the basics - an aim, process mapping, small tests of change as well as audit and feedback. In my local context, I have proven a couple of things: 1) These techniques works and 2) QI projects are hard work. I doubt that either of these things are news-flashes.
When I was in my Master's program I wrote a paper about developing a methodology to assess the quality of prenatal care at any given facility. I always thought that someday, I would write that paper again in a way that would allow for publication. The urine culture project was a spin off of that paper. It was a test to see if the methodology was workable in the real world. As I wrestle with writing up the urine culture project, i am wondering if I need to go back to the original paper. Does the urine culture project only make sense in the context of that larger body of work? Is it only in the two papers together that I find the material that is generalizable, that transcends APD and allows others to see a new way of thinking about high reliability prenatal care. If this is true, I am in trouble...I barely have enough time now to reflect and write. If I add another, more challenging, piece of work to my plate, I fear that nothing will get done. Except for the Flu vaccination project that I am starting. I hear that pregnant women are especially vulnerable to H1N1...
Here I go again.
It's not that I haven't been writing; I just haven't been writing the hand hygiene piece. I allow myself to agree to other writing tasks and then I postpone the writing task that doesn't have an external deadline. But I have a renewed interest in getting this manuscript finished.
I spent the last week at "summer camp" for grownups committed to improving healthcare. I gained some new insights on my hand hygiene work from a criminologist. Yes, it seems there are parallels between my work and crime prevention! (How that never dawned on me before may be the stranger realization.) In any event, I have some good, new ideas about how to approach the next set of learning. But first, I absolutely must finish telling the current story. (It helped that the leader of our writing collaborative was also at summer camp. One look from him, and I squirm.)
So--this afternoon, between other things, and with a pile of things on my desk, I opened up my draft manuscript and started writing again, this time in the Results section. The way I see it (interpreting the Squire guidelines as they relate to my work) the task in this section is to answer two questions:
1) Did we do what we said we would do (in the methods)? (how well?)
2) Did it work? (ie, did hand hygiene improve, and did we have fewer infections?)
Obviously, the second question is easier to write the answer to--and is the stuff of "normal" scholarly manuscripts. The first question is the messy work of quality improvement, and of course the answer is no, not exactly--ie, we approximated what we set out to do, but there were deviations from the plan that are probably important to understand if you want to understand what about what we did worked.
I only got about a paragraph written, but I think the important part was figuring out that questions 1 and 2 need to be answered. It was helpful that back at the beginning of the project I laid out a 3 page document that outlined who was to be involved, in what role, and what the various workgroups were charged with. It helps to see that in writing so I can reflect on what did and didn't happen according to plan.
The SQUIRE guidelines continue to be helpful as signposts for me. It may become second nature to write this kind of paper...later.
Reading Sue's entries, I have to say that I feel pretty lucky to write in an environment where I can access the literature with a few keystrokes, and am surrounded by people who find my scholarly work familiar, at least on the surface.
Although I enjoy my job, there are things that make it hard to work in a non-academic setting. The first is that "access to information isn't free" and the second is that "honest feedback is hard to find". I recently learned that my access to the Dartmouth Biomedical Libraries has been turned off. Apparently, my work with The Dartmouth Institute and the SQUIRE project does not qualify me for access. Without the library, my ability to access information has turned into a patchwork quilt. I can get abstracts off the web and some articles through the on-line library to which APD subscribes, but trying to do a comprehensive literature search is next door to impossible. At best, I find this mildly annoying. At worst, I think that limiting access to information must adversely affect the spread of good practice. Even if I succeed in publishing my work, who will see it? Is it worth expending a tremendous amount of time and energy to create a paper that collects dust on some obscure virtual bookcase? I get a sense that we need other ways to disseminate good ideas and good projects - ways that are more egalitarian that the traditional journal and library system.
Which brings me to the second point. During my training, it was easy to get feedback on my work. Sometimes, I got feedback even when I did not want it or did not have the time to deal with it. Now, I live in a feedback free zone. Perhaps my colleagues are just too polite, but I can't remember the last time anyone said anything other than "nice job" in reference to my work. I don't mind hearing those words but a little constructive criticism now and then would be helpful. Because of the absence of meaningful feedback at home, I am compelled to put my work "out there" for all to see and critique so that I can continue to learn and grow.
This attempt to publish from a non-academic setting is daunting. The system isn't set up to support or reward this type of work. From the lack of an IRB to the limited library access to colleagues who have different priorities, everything conspires to make this hard. This really is not about me and one little paper about Urine Cultures and pregnant women, it is about structure. There are two different healthcare worlds out there and we are only hearing about the experiences of one of them. I can't help but wonder about what is lost in the process.