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

11 Mar, 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.