SQUIRE Blog
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.
The Difficulty with Data
Susan Mooney
This should be simple but its not. For over a year now, I have been tracking my clinic's urine culture collection performance. A while ago, I hit on a methodology that works well for data collection. (In truth, it only works well for me - the data collector). Our prenatal records are scanned onto the computer's public drive after each visit. The records are filed by the Estimated Due Date. For example, everyone who is expected to deliver in September is filed under that month. Data collection for this project goes like this: I go to the public drive and locate the patients who are currently about 20 weeks pregnant (I chose 20 weeks to make sure that everyone was well beyond the 1st trimester). I locate these patients by opening the appropriate "Due Date" month. I have a big Excel spreadsheet where I keep all the data. I record the patient's name, medical record number, month Due and service. If the record indicates that a UA C&S was done, I put a "yes" in the "documentation" and the "done" column. If the record is blank, I put a "no" in the documentation column and go to the EMR to see if a UA C&S was done. In this way, I track documentation and culture rates. Initially, I just used a bar graph to show the results. Finally, I reached a point where I have enough data to use a p chart. Here is where it gets a little confusing. I am looking a patients who are 20 weeks along, but I ID them by the month that they are due and I carry out the analysis using that month, not the month that I recorded the data. For practical purposes, this means that my x axis always includes future dates.
Here's the problem. This data collection and analysis makes perfect sense to me. But, other people don't seem to get it. I present these data to my office staff each month and it took months for me to get beyond the question - "wait, how come the months on the x axis are in the future?" If I need to explain this to my staff month after month, there is clearly a problem. Additionally, I don't know what to do about putting these data in a paper...
So, I am wrestling with a way to re-engineer my data analysis. But, I wonder about doing this. By writing up this project, I am trying to truly represent what I did during the project. How do I acknowledge the limitations of the ongoing data feedback without throwing it out altogether? I don't want to misrepresent what we have done but I want to make the results clear to a casual reader. I am about to do this month's data collection so this is a good time to think about this challenge. One big lesson I have learned. Pay attention when the folks on the front line tell you that they don't get what your data is trying to tell them. It is critically important to make things simple. Otherwise everyone gets lost in the confusion and misses the larger message.
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Why is it so hard to write?
Kathy Kirkland
Topic: Miscellaneous
I've been participating in a Writing Collaborative here as part of the Leadership Preventive Medicine Residency. For our session this Friday, the call came out for "your current draft" to be submitted in advance so that we could work collaboratively to improve each other's work. At the last group meeting, I was exposed as being a "writer in theory" ie I did not really have a draft. (I was not the only one!) One person pointed out the obvious fact that I have been talking about and presenting this topic "forever"--so what is the hold up?
Why is it so much easier to put together a powerpoint, or a workshop on a topic, than it is to write it as a paper? Some of it has to do with the permanence of the written word--the same reason it may be better to express anger in person or on the phone rather than in writing where it can be read over and over again, ruminated over, and develop a life of its own. Writing it down makes the stakes higher. It activates the perfectionist in me, and makes the task ahead feel enormous and never-ending. Even writing a first draft brings on inevitable feelings of vulnerability...."You actually think that?"
A benefit of the Writing Collaborative is that it turns out that everyone has these feelings about writing. We all skulk in thinking we are the only ones finding the process painful, or avoiding it altogether, and there is this relief in learning that our experiences are possibly universal. I think it helps to know that.
The other benefit is the publicness of the forum. Although it is a small group of us, failure to produce any work is obvious. And because it is a small group, multiple failures to produce work leaves us nothing to collaborate on, except how pitiful we all are.
So, with all this in mind, I have actually spent some time this week moving my draft forward, and submitted it for group input on Friday. I've gotten 5 pages of intro and methods on paper! The work ahead still feels immense but better than a blank page.
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Back in the saddle--or in the saddle for the first time
Kathy Kirkland
Topic: Background Knowledge, Local problem, Intended improvement, Study question
How often do you get to use the excuse: I couldn't write because there was a pandemic? Well, at least once, I guess. I've been busy reading health alerts and implementing algorithms for testing and treating, and, in short, tracking the emergence of the new H1N1 influenza in the US and even right here in New Hampshire. Now that things have reached some degree of equilibrium, I turned back today to my hand hygiene improvement paper, and actually wrote an introduction.
I found the Squire guidelines helpful in that they laid out what was necessary. In the past I tend to go on and on in an introduction--after all, the background in some ways is what you know best when you've done a project like this. But the guidelines reminded me to stick to the key points--the introduction should be just enough to explain why you did the work in the first place--if people want to read more detail, they can go to the references and read it there. Which reminds me of a problem I have writing introductions: I never can just pull out of my head the exact reference for what I want to include. I know when I write a sentence that needs a reference, so I just write in a placeholder [REF]--then later I have the tedious job of going back and trying to figure out where the concept originated. Do other people have that problem? I've always felt it as a failure of my scholarship that I don't have all this organized in my mind.
I spent about half an hour writing and was able to get down on paper (without references) the basic #3-6 within introduction: Background Knowledge, Local Problem, Intended Improvement, and, I guess, Study Question. I say I guess because I'm not clear on the question, or have not yet quite framed it as a question. "Is it possible to improve hand hygiene?" "Is it possible to achieve sustained high levels of hand hygiene?" "Do these interventions work?" "Were all these components necessary?"
Maybe I need to spend some time thinking more about the questions. OR maybe after I write some of the rest of the paper, the questions will become clear, and I will go back and revise this part.
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Tracking the Evidence
Susan Mooney
Evidence Based Medicine
All of the prenatal care guidelines that I have looked at recommend screening pregnant women for asymptomatic bacteruria. They all make the claim that pyelonephritis is a primary cause of preterm labor and delivery with all the attendant morbidity and mortality. They all claim that asymptomatic bacteruria is a leading cause of pyelonephritis and they all draw the same conclusion that screening for and treating asymptomatic bacteruria is beneficial. The logic seems irrefutable. So, as I sit here contemplating the background section of my paper, it seems as though it should be simple to look at the primary literature upon which all these guidelines are based. But a quick literature search has disavowed me of this thought. I can find lots of papers that argue that a dipstick is as good as a culture and I can find papers showing that, yes, pregnant women in sub saharan Africa also have asymptomatic bacteruria. So far, I have not found one prospective, randomized, controlled trial that demonstrates the reduction in preterm births associated with screening for and treating asymptomatic bacteruria. I wonder if such a trial exists and doubt that it does. And then I think, do you really need that level of evidence? Further, when you start a QI project, can you rely on guidelines and expert recommendations or do you need to dig into the primary literature? Ultimately, when do you stop analyzing and start acting? It is just a urine culture, after all.
Evidence Based Improvement
Things get even muddier when I try to look at the literature to see if others have undertaken a project like mine. The short answer is no. Most QI literature reports on larger initiatives that are driven by academic institutions or QIOs. It is extraordinarily difficult to find projects that describe how someone like me solved a small problem like mine. If I branch out, to look at something like IHI posterboards, I am more likely to find work that resembles my own. But much of that work is not peer reviewed and lacks academic rigor. If I am looking to publish, can I use such evidence? The reality is that, as I do my improvement work, I "steal" good ideas from where ever I can find them. I try them out, adapt them, keep them and discard them based on whether or not the help or hinder the process. Can I be that honest in a publication?
Balancing Again
It seems that I am back to the balancing act: trying to decide how much time to spend looking through the literature to flesh out the background section of this paper while acknowledging that such work will have very little impact on the front line. The people that provide prenatal care at APD are very unlikely to question the guidelines or to challenge the evidence. By the same token, they have very limited time to dedicate to a QI project. I have not yet convinced them all that improving the work is part of the work. Perhaps a solid literature review would help me in the endeavor. Regardless of the ultimate benefit, it is clear to me that I need to do more work at the library before I can start to write this section of the paper.
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