Explanation & Elaboration

4. Local problem

• Describes the nature and severity of the specific local problem or system dysfunction that was addressed

Example

"A completion rate of 90% [for screening colonoscopy] is considered acceptable and since the start of our programme has been accepted by the UK endoscopy community. Median colonoscopy completion rates found in an audit in three regions in the United Kingdom were between 57% and 73%, depending on how completion is defined, although some institutions report adjusted completion rates of more than 90%. In the United States, crude completion rates of 95% have been reported in large series (such as one series of 3465 colonoscopies), suggesting that a 90% completion rate is achievable in routine practice. The impact of incomplete colonoscopies on the success of a proposed national colorectal screening programme has been highlighted. We were aware that our colonoscopy completion rate was low, and we wished to attain the suggested standard so that our patients would benefit by avoiding subsequent barium enema or missed lesions." [20]

Elaboration

The introduction to a quality improvement paper should explicitly describe the existing quality gap. To be as specific as possible, authors should describe the known standard or achievable best practice, and then provide evidence that the local practice is not meeting that standard. These authors specified that 90% colonoscopy completion rates are achievable, yet local completion rates only range from 57% to 73%.

Comparing and contrasting local, regional, and national outcomes helps to frame this study against other outcomes. By comparing colonoscopy completion rates in the UK with published completion rates in the US, the authors provide documentation that better performance is both quantifiable and achievable. In the absence of a known achievable standard of care, authors need to state their rationale for the level of performance they set as their goal.

Although the implications of the quality gap need not be described in detail, a brief summary of the individual patient, local system, and (if applicable) national implications help to frame the study's importance. In the above example, the authors point to documentation that suboptimal colonoscopy completion rates can hinder a national healthcare initiative by allowing missed diagnoses, thus increasing morbidity and mortality, cost, and medico-legal risk. Further implications of the quality gap can be addressed in the discussion section (see guideline 15. Relation to other evidence and 18. Conclusions.

References

20. Ball JE, Osbourne J, Jowett S, Pellen M, Welfare MR. Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study. BMJ (Clinical research ed.). 2004;329(7467):665-667.

to top ^