QIR and SQUIRE: continuum of reporting guidelines for scholarly reports in healthcare improvement

This paper is freely available online under the BMJ Journals unlocked scheme, see http:// qshc.bmj.com/info/unlocked.dtl Significant problems with the quality and safety of care seem endemic in all healthcare systems. In a recent systematic review of case note review studies, over 9% of patients admitted to hospital are harmed by error. Furthermore, many patients do not get the treatment that would be effective for them and many more have care that is inefficient. When any problem is investigated the solution may appear simple. However, getting necessary systematic change always seems difficult. The quality improvement movement, and latterly the safety movement, came late to health care compared to other industries. Perhaps this is in part a reflection of the additional complexity of health care. While problems with care are not new, in the past 20 years or so there has been a huge increase in the number of effective treatments and in their complexity, with an increase in public concern about the safety and quality of care. There is much theory and practice to be learned from other industries. But theory alone is not enough and there is a clear imperative to find practical ways of addressing quality and safety in local healthcare settings in a robust and reliable way—we owe this both to our patients and to ourselves. In 1991 we helped to found the journal now called Quality and Safety in Health Care. We sought to provide a forum for the exchange of scholarly ideas, original research, debate and discussion, and examples of good practice. The survival and growth of the journal attests to the importance of the field and those initial aims. Although there may now be an improved understanding among a few about what is wrong with health care and how it could be put right, the fact that systematic problems with care—for example, infection control in hospital (present seven years ago)—still exist in much the same way, suggests there is a long way to go in the practical application of quality improvement methods. Finding out what works in the real world of clinical practice that could be of use to others facing the same problems and then disseminating this was one of the initial aims of Quality and Safety in Health Care. Initially we encouraged and published such reports. But we did not provide any specific guidance; we asked authors to use the standard IMRaD (Introduction, Methods, Results and Discussion) structure that is used for research papers and we received and published very few. Providing a platform for the dissemination of examples of good locally based quality improvement work was proving hard to achieve. Experience at conferences, where many examples of innovative, stimulating and even inspiring projects were being presented, suggested that much work was being done, but that little made it as far as publication. Our own local intelligence suggested that even more interesting and potentially useful work was not even being presented at conferences. This was undermining the potential for wider sharing and uptake of experiential learning. Several reasons explained the sparse publication of quality improvement reports. First, leaders of such projects were rarely academics and did not have either the incentives or perhaps the skills and experience to write for publication. Second, what drove them, and where they would invest any extra time and energy, was not writing what they had done, but the challenge and rewards of further improvements to care. Third, there had been few journals interested in publishing ‘‘grassroot’’ quality improvement work. Finally, the nature of quality improvement work differs in a number of ways from research. A fundamental difference between quality improvement reports (QIR) and the reports of original research is that research seeks broadly to produce generalisable results but quality improvement work seeks to test the application of those results. Thus, trials of thrombolytic treatment in acute myocardial infarction sought to determine whether thrombolysis reduced subsequent mortality, such that the results could be generalised to coronary care units and medical wards treating such patients and a general statement could be made that ‘‘all patients with myocardial infarction who meet defined criteria should get thrombolytic therapy’’. A subsequent local audit or quality improvement project would seek to assess whether all eligible patients were appropriately treated with thrombolytic therapy. If problems were found, then local quality improvement would go on to define the local problems and then seek to change the system of care so that ‘‘all patients with myocardial infarction who meet defined criteria do get thrombolytic therapy’’. The results of such a study may not be generalisable to other coronary care units in the same way as the preceding research evidence—they may be unique to the local context of the unit in which the audit was undertaken. None the less, a well written and structured quality improvement report may include generalisable methods and strategies for change from which others undertaking similar audits would benefit, thus disseminating good practice. The interest to others is as much in the details of strategies for change as in the outcome. A problem faced by those intending to write about their quality improvement work was that Supplement