Standards for Quality Improvement Reporting

Excellence (SQUIRE)

Frank DavidoffSusan KirshGreg Ogrinc

VA CyberseminarDecember 2, 2008

Objectives

• Understand the origin and development of the SQUIRE publication guidelines

• Identify how one author has used the guidelines to publish her work

• Review the SQUIRE guideline website

• Start on your homework for Dec 16

Why publication guidelines?The SQUIRE story

Frank Davidoff

VA Cyberseminar

December 2, 2008

The Problem:Failure to publish QI work

1. Why is it a problem?2. Why isn’t it published more often?3. Why is it so hard to write about QI?4. What are the SQUIRE publication

guidelines?5. How can they help?

Failure to publish QI work: 1. Why is it a problem?

• Fails to advance the science

• Limits transparency, public accountability

• Slows dissemination of proven interventions

• Less stimulation of new ideas, innovation

• Permits unnecessary/redundant work

• Limits learning from mistakes

Failure to publish QI work: 2. Why isn’t it published more often?

• Done by busy “front line” professionals– More concerned with local change than discovering

generalizable truths

• Lack of training, experience in research, publishing

• Academic incentives often not relevant• Editors, peer-reviewers unfamiliar, skeptical• Writing about QI is hard

Failure to publish QI work:3. Why is writing about QI so hard?

• The heart of the matter:– QI is NOT the same as drugs, tests, clinical procedures

• QI is performance change, driven by experiential learning• Context-dependent• Interventions are complex, multi-component• Problems occur at various organizational levels, type varies• Interventions adapted, evolve in response to feedback

(reflexive)• Change is fragile, results unstable

• Result: uncertainty about what evidence is needed• Little guidance available on how to study, hence

on how to write in this area

Failure to publish QI work:4. What are the SQUIRE guidelines?

• Checklist: 19 items, information to consider in QI reports• Models: Other guidelines (e.g., CONSORT, STROBE, etc.)• Focus: Content, rather than study design• Development: Several years, iterative process, multiple

endorsers• Immediate purpose: To increase completeness, precision,

transparency• Ultimate purpose: To encourage more and better reports• Target audience(s): Mainly authors, but also reviewers,

editors, users of QI reports; funders• Dissemination: website (squire-statement.org), articles (6)

Failure to publish QI work:5. How can SQUIRE help?

• SQUIRE does:– Offer guidance on:

• Content: e.g., context-dependence, complexity, reflexiveness• Organization: IMRaD format, • Methods: evaluation of impact, and explanation of

mechanisms

• SQUIRE doesn’t:– Apply to reviews, commentary– Demand rigid or mechanical use– Prescribe specific study designs– Define intended audience, readership, journal– Clean up a messy room; just turns on the light so you can see what

needs to be cleaned up

Failure to publish QI work:Summing up

• People often don’t publish solid, important QI work

• Failure to publish is a problem• Lots of reasons for this failure

– QI is not the same as most clinical interventions– Writing is hard– Little guidance on studying, writing, publishing

• SQUIRE guidelines encourage publication of complete, accurate, transparent reports

• Use them, share that experience with us!

Rigor, Relevance, and Rigor, Relevance, and Reality: WorldReality: World

A Tale of Two Papers A Tale of Two Papers Using SQUIRE GuidelinesUsing SQUIRE Guidelines

Susan Kirsh, MDSusan Kirsh, MDLouis Stokes Cleveland VAMCLouis Stokes Cleveland VAMC

October 24, 2008October 24, 2008HPECHPEC

QI is hard; publishing QI is very hard.QI is hard; publishing QI is very hard.

Continuum of Quality Improvement and

Research:Rigor vs. RelevanceOperations

“Relevant”Context-Dependent

Problem SolvingQuantitative >, <, or =

QualitativePre-test post-test or

quasiexperimental designsTends to be NON-LINEAR

Research

“Rigorous” Identify generalizable

knowledge, i.e.,Eliminate Context

PublishableQuantitative>Qualitative

RCTs RuleTends to be LINEAR Continuum not a dichotomyContinuum not a dichotomy

Goal is relevance moving as close to rigor as one canGoal is relevance moving as close to rigor as one can

Potential

Synergy

*** Danger ****** Danger ***Linear Fallacy of Research and QI: Widely-held assumption that social and biological systems can be largely understood by dissecting out micro-components and analyzing them in isolation.

A P

S D

APS

D

A P

S DD S

P ADATA

The journey up the ramp of complexity is NOT linear.

Com

ple

xit

y

Time

Com

plex

ity

Time

APS

D

P PS D

A P

S DP

SD

AP

SD

Challenges

Opportunities

P

D

AS

PD

Revised Conceptual Model of Rapid Cycle ChangeTomolo, Lawrence, and Aron, QSHC, in press.

Legend:P=Plan D= Do = Barrier = Direct flow of impact S=Study A=Act = Lingering background impact Arrowhead = Feedback or feedforwardDifferent Sizes of letters and cycles and bolding of letters = denotes differences in importance/impact

ResearchResearch

Project is fixed Context

must adapt

Context is fixed

Project must adapt

Practice

• Target of the interventions – the context - cannot as easily be controlled, randomized or matched in the same way as can patients

• Quality programs usually cannot be controlled or standardized

• The context of the intervention is constantly changing

Why? In short, the issue is CONTEXT

T. Greenhalgh

Initial design: pre-test post-test with 44 patients

Reviewer comments - 3 times Lack of recognition that this was a quality

improvement project Put ‘QI’ in the title

Organization/Format issues Inserted SQUIRE as signposts and follow a familiar

format

Reviewer #2 comments re: first Reviewer #2 comments re: first versionversion

“The major problem is the lack of a control group. The participants were selected based on high levels of particular measures.”

“The second problem is that the people are treated in clusters, and that therefore the independence assumption of the statistical tests is violated”

“An appropriate method of analysis should be used– such as multilevel models, generalised estimating equations or Huber-White sandwich estimators.” (Note that subsequent reviews from this

reviewer were even worse!

ResponseResponseChanged design to quasi-experimental: Added a control group – matched, concurrent, but not randomized. Use as much rigor as possible: Consider sources of bias and address wherever possible eg., regression to the mean

Required 3 revisions overallPersistence pays offIt was a much better paper as a result of the reviewers’ comments. Leave your ego out of it.

Qualitative work adds another dimension that makes quantitative data more meaningful

Used framework of Grol model to add structure and rigor

Triangulation

Reviewer commentsReviewer comments “The majority of the paper is placed

in a section entitled ‘Methods and Conceptual Framework’. It is easy to get lost in this section, and difficult to find key information. It would be worth attempting switching the structure to the more common Introduction, Methods, Findings, Discussion/conclusion format. For example, the methods were unclear.” More signposts needed

Changes based on Changes based on reviewsreviews

Use of SOME signposts of SQUIRE, but not all applicable

Less than previous paper

This paper also required several revisions, but it is a much better paper as a result. If you can choose a

reviewer, choose one who will be critical and thoughtful, but unbiased.

Final lessonsFinal lessons

Begin with the end in mind Squire guidelines can help more at the

beginning than at the end. Make conceptual model explicit and

specify context as much as you can. Plan for that (choose a comprehensive

framework, e.g., CFIR, PARIHS, Greenhalgh, Grol)

You cannot document too much Recognize the rigor/relevance balance

and consider the reviewers’ background.

www.squire-statement.org

Charge to Participants

Between now and Dec 16, review the SQUIRE website

www.squire-statement.org

1. What works well about the guidelines?

2. How does the website help understand and use the guidelines?

3. What questions remain for you about the SQUIRE guidelines?

4. How can the website be improved?

Summary• Thanks to the SQUIRE web team: Leslie

Walker, Susan Mooney, Scott Chesnutt, Scott Hepler

• SQUIRE guidelines offer guidance– not intended as “must haves” – guidance to write about your improvement

efforts– share important findings with others

• Several tools available– SQUIRE articles (QSHC supplement, online)– www.squire-statement.org