Three Questions … A Quick Glimpse Into WHO is Using SQUIRE and WHY - March 2010

We asked Dr. Maxine Power, National Improvement Lead for Quality and Productivity Department of Health Salford Royal Trust in England three questions about SQUIRE, and here is what she had to say:


1. How do we use the SQUIRE guidelines?
Salford Royal is an academic medical centre with approximately 800 beds in the North West of England. Two years ago we began designing an ambitious quality improvement strategy to save lives and reduce harm by 50% in three years. The drivers of change which we identified were enhanced leadership, measurement of change, programmatic approaches to improvement and a skilled workforce capable of delivering the change. The work portfolio for each of the four drivers was developed and within the 'skilled workforce' we designed a program called 'Clinical Quality Academy' in which teams of three, led by a physician or surgeon came into a nine month learning collaborative. Whilst learning the science of improvement, they designed and implemented an improvement project. Importantly however, we also decided that the graduation criteria from this program would be a manuscript. It seemed sensible to include the SQUIRE guidance into the curriculum, which we did. At the first learning session we gave the teams the Guidelines and a QI manuscript and asked them to rate how close to the requirement the manuscript was. In short, they hated the manuscript. Most of the doctors were from very traditional research training backgrounds and this first exposure to SQUIRE was distinctly alien. At that point we decided to encourage the teams to begin to write their monthly reports into the SQUIRE framework, building month on month. We predicted that this would help the teams identify the gaps in their work, focus their thinking and help them build towards a final manuscript. At the first invitation 3 teams usedthe SQUIRE framework.

2. What works?
It seems as though the teams who have been using the framework have moved much more quickly in their projects (maybe they are self selecting high rollers - who knows) but the one's who have been slower to adopt have also benefited from the progression of filling out the template as thy have gone along. We aren't declaring victory just yet though. The journey to a comprehensive QI manuscript is not without its bumps and I think the teams thought that this would be easy. They are learning that to do QI rigorously that it requires just as much sweat and blood as a traditional manuscript (possibly even more). For us, using the template highlighted important issues around Ethical issues very early in the process and I think that debate and discussion was extremely healthy for the group. In the sixth month of this program, seven of the nine teams are using the guidelines to frame their monthly reports. Lastly, I think the SQUIRE template will produce papers in a shorter turnaround but we'll have to wait and see what we learn from that prediction.

3. What could be better?
The template has worked well but I think we do suffer from a shortage of really high quality QI papers which map directly onto SQUIRE - this is what the community needs so that the pain of the initial 'mental block' is removed by someone else's interpretation of the particular heading. All in all this is a journey and my personal view is that we will look back and see SQUIRE as a cornerstone in dramatically improving the quality of QI manuscripts and peer review.

 

Three Questions … A Quick Glimpse Into WHO is Using SQUIRE and WHY - December 2009

Nancy Armistead, MPA is the Executive Director for the Mid-Atlantic Renal Coalition.
Realizing the applicability to their work Nancy and colleagues attended SQUIRE training at IHI last year. Nancy then promoted SQUIRE at a Network training session, one of the Network physicians presented on SQUIRE as a model for development of our QI initiatives. As a result they have submitted a paper for publication using the SQUIRE Guidelines. Here are Nancy's answers to our three questions.

1. What have you found most interesting about SQUIRE?
We appreciate the recognition that research and quality improvement are related but different activities, each with their own merits. We like that SQUIRE provides a framework for the design and reporting of QI projects which allows us to learn from a body of work that was not previously visible.

2. How has SQUIRE helped in writing about your improvement work?
Having a template is helpful in allowing several individuals to effectively work on the write up of a single project and brings consistency to our QI efforts. The framework assures that we're thinking about and addressing all salient components of our project  thereby strengthening the overall project design, implementation and learning from experience.

3. Has SQUIRE influenced how you plan for future work?
One of our challenges is the use of evidence based interventions to guide our quality improvement initiatives. We intend to use SQUIRE in project planning, deployment and final reporting moving forward. Not all projects will result in publication, but we'll have comprehensive end of project reports to share with our review boards and funding agency, Center for Medicare & Medicaid Services. We'll use what we learn to plan new quality improvement initiatives.

Three Questions … A Quick Glimpse Into WHO is Using SQUIRE and WHY

Sarah Frazer, BA, BSc, MIHM, FRSA

Dr. Frazer is well known in healthcare for her work on how good practice spreads, how improvements can be made at practitioner level and how organizations and teams can best work together. She is a speaker and workshop presenter and has written numerous papers, articles and guides around the topics of the spread of better practice, complex systems, culture and behavior in organizations, breakthrough collaborative and improvement methodologies, and is the author of "Undressing the Elephant; Why Good Practice Doesn't Spread in Healthcare"

1. What have you found most interesting about SQUIRE
SQUIRE is perhaps not only for writing up completed improvement work. We've been using the guidelines in two proactive ways. One method is at the start of a project to use SQUIRE like a meeting agenda and to work through the topics. The headings enable a comprehensive discussion and more detailed planning than before. They work as excellent reminders for all aspects of improvement project implementation. Another way is to use them as a midway project review. In this case we use them to draft a case study as though the project was completed and we are writing some time after the end. In this way we check progress and do future planning that is more implementation orientated. The process provides insight into work still to be completed if the intended
outcomes are to be achieved.

2. How have the guidelines been helpful in writing about your improvement work?
They provide a comprehensive list of what can be covered. We do have a fair amount of discussion on some items and disagreement as to whether they should be included in the write-up. This is interesting in itself and we usually end up adding the section in after the debate! Where context, history and funding is concerned the guidelines are an excellent step forward in helping those who read the write-ups to understand how applicable the results may be to their own situation. There is some evidence of some projects not wishing to use the guidelines because they appear too onerous. My feeling is this is precisely what the guidelines are intending to resolve - the quick write up that lacks fidelity.

3. Have the SQUIRE guidelines influenced how you plan for future work?
Yes. We use them as a guidelines for improvement project planning. It can be frustrating to get to the end of the project and realize some effort at the start on, for example, addressing ethical issues, would have meant a more efficient and effective process and better outcome. For me personally I am a lot more critical of what I read. I use the guidelines as my benchmark. If improvement reports leave out many of the headings then I ask myself, and others, why the omission and what impact does this have on the result and its generalizability.

“Outstanding SQUIRE Presentation”

Greg Ogrinc, MD, MS, and Kathryn Kirkland, MD, presented Medicine Grand Rounds at Dartmouth-Hitchcock Medical Center on Friday, September 11, 2009. The presentation contained an overview of the need for and the development of the SQUIRE guidelines along with an in depth example of using the guidelines to write a paper. The video stream for the presentation is available here: http://www.dhslides.org/mgr/mgr091109f/f.htm

 

 

Three Questions … A Quick Glimpse Into WHO is Using SQUIRE and WHY

Neesha Naik Choma, MD

Dr. Choma is a member of the Department of Medicine, Division of General Internal Medicine and Public Health at the Vanderbilt University Medical Center and on staff at the Department of Veterans Affairs in Nashville, TN. Dr. Choma recently had a QI paper accepted by Cardiovascular Quality and Outcomes. Here is what she has to say about SQUIRE.

1. What have you found most interesting about SQUIRE?
I like the way SQUIRE guidelines seamlessly merge the elements unique to quality improvement (QI) research with current scientific literary practice. Quality improvement in healthcare is receiving heightened attention as an important practice in care delivery today, yet the intricacies and subtitles of QI research remain unfamiliar to many practicing providers and administrators. As it disseminates and becomes incorporated into the medical community at large, SQUIRE guidelines will help to increase awareness and change general familiarity with QI.

2. How have the guidelines been helpful in writing about your improvement work?
I primarily used SQUIRE guidelines as a checklist. I actually started writing my manuscript before I was aware of SQUIRE and had to resort to extracting recurrent "themes" from existing QI literature to formulate a paper outline. I found out about SQUIRE prior to manuscript submission and used it to refine my paper and ensure that it was thorough and met scientific rigor.

 3. Have the SQUIRE Guidelines influenced how you plan for future improvement work?
Definitely. It is extremely helpful to have a set of scientifically based guidelines to refer to as I continue to plan QI work and generate manuscripts. Now that I am aware and familiar with the guidelines, I will use SQUIRE as a starting point when planning QI projects. It will be helpful to ensure various key QI elements are considered, designed, and included early on before unrolling actual interventions.

 

 

 

SPINE Journal Adopts SQUIRE Guidelines

SPINE has joined the leaders in healthcare journals by adopting the SQUIRE Guidelines in their Instructions for Authors. Recognized internationally as the leading subspecialty journal for the treatment of spinal disorders, Spine is a peer-reviewed, bi-weekly periodical that considers for publication original articles in the field of Spine. Spine request in their Instruction for Authors that all manuscripts describing quality improvement studies to follow the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines.

Canadian Journal of Diabetes Endorse SQUIRE

In the Editor's Note, of V32,#4 of the Canadian Journal of Diabetes, Heather J. Dean, MD, FRCPC, Editor-in-Chief stated "The Canadian Journal of Diabetes is proud to be one of the international journals supporting these important new publishing guidelines". She goes on to state "these guidelines will substantially enhance scholarship in the field of QI." Dr. Dean then summarizes her editorial with "The Canadian Journal of Diabetes eagerly awaits authors who submit manuscripts and comply with the SQUIRE Guidelines and, even more fundamentally, who use the guidelines to inform the design of the QUI project they undertake." With that the journal also published the "Development of the SQUIRE Publication Guidelines" in the same journal publication showing their commitment to SQUIRE.

 

Willkommen SQUIRE!

SQUIRE Guidelines Make International Debut at the 2009 International Forum on Quality and Safety in Berlin Germany

Over 125 interprofessional delegates from around the world participated in a workshop session on the SQUIRE Guidelines. The workshop focused on the development of the guidelines; the details of describing the context of improvement projects; and featured an audience review of a section of a manuscript. This hands-on learning approach to SQUIRE was well received by the participants and felt to be very helpful even ... Wundervoll!