Background

Medicine has made many efforts over the years to improve the care it delivers to patients, particularly since the methods of science were introduced into the profession about 200 years ago. These advances in knowledge and techniques – more effective, less toxic drugs, and better surgical procedures, for example – can dramatically improve the outcome of patients’ clinical conditions. But as healthcare has become increasingly complicated it has also become clear that the care we actually deliver to patients is not always the best and safest care possible.

Roughly 20 years ago, in response to this situation, a number of health care providers began to look seriously into the reasons why the clinical care that is delivered fails so often to be up to the highest possible standards  – and is sometimes even unsafe¹. These pioneering thinkers soon noticed that industries such as automobile manufacture and aluminum production had made enormous progress in improving the quality of their goods and services, and in manufacturing these products more safely and efficiently, through the application of a “science of improvement”². They promptly began to apply lessons from this new-found science to health care. Among the most important of these lessons was the insight that suboptimal and unsafe care results from poorly organized care systems, such as hospitals, office practices, provider networks, more often than it does from the actions of incompetent or misguided individual providers. In effect, poor health care turns out to be more of a social and organizational problem than a strictly personal, biological, or clinical problem. It has also become increasingly clear that healthcare systems, like all social systems, are extremely resistant to change, and that studying the interventions used to change them can be very difficult.

Given these many challenges, it is not surprising that as recently as 10 years ago relatively few reports of systems-based healthcare improvement and safety were being published, and that the articles on the topic that did get published were often unclear, incomplete, poorly organized, and unconvincing. Other factors appeared to have contributed as well to the slow and inadequate development of the published literature in this area. For one thing, intervening to change the way groups of healthcare providers perform is considerably more complicated than ordering diagnostic tests, or giving pills to patients. Besides, most of the people who are working to improve healthcare are clinical practitioners whose main interest is in making care better for their patients locally, rather than reporting their improvement work to the rest of the world. What’s more, writing is hard.

Unfortunately, failure to publish improvement work has had many regrettable effects: it retards development of the field as a science; limits the discipline’s credibility and accountability; slows the spread of interventions that have been shown to work, while failing to discourage continued use of ineffective interventions; limits learning from mistakes; and reduces the stimulation of new ideas, inventions, and innovations. In 2005, a small group of interested professionals drafted an initial set of publication guidelines for improvement, in an effort to encourage greater publication of healthcare improvement work, and to make the published literature on improvement more complete, accurate, and coherent³. This initial draft was modeled largely on the CONSORT guidelines, a list of the key information items that should be included in published reports of randomized clinical trials⁴. After extensive critical review, a revised version of the improvement publication guidelines, titled the Standards for Quality Improvement Reporting Excellence (SQUIRE), was published in 2008⁵. The main target audience for SQUIRE was authors who are writing about their completed improvement projects. But SQUIRE’s developers also hoped and expected that practitioners and researchers would find them useful in designing and studying improvement interventions, and that editors, peer reviewers, and funders would find them useful in their work.

What is SQUIRE?
In its present form, SQUIRE is a list of 19 items that describe briefly the most important things readers need and want to know, first, about the changes people make to improve the performance of healthcare systems and, second, about studies of how such changes are made. These 19 items provides a framework or checklist that reminds authors what they should think about including in their publications on improvement work, and how that information might best be organized. The checklist is available on the SQUIRE website (http://squire-statement.org), along with a longer “explanation and elaboration” or “E&E” document that provides more detail about each of the SQUIRE items, and other relevant information about SQUIRE.

What special features of improvement work are reflected in SQUIRE?
Like all social change programs, and unlike many clinical interventions such as the use of diagnostic tests, drug therapy, and clinical procedures, improvement interventions usually consist of multiple elements or components. They can include, among others, actions and procedures such as education, audit and feedback practice guidelines that are designed to change attitudes and incentives, shift organizational culture, and/or give providers new skills, to improve communication, and to redesign care processes. These interventions are not only hard to standardize but also depend entirely for their effectiveness on the local context in which they are put into practice; moreover, their impact is often unstable, changing over time in response to feedback about whether they are working. The SQUIRE guidelines make a special effort to capture all of these relatively unique features of improvement work.

SQUIRE

Also distinguishes carefully between thinking done and actions taken to change the performance of healthcare systems, and studies of that change-making process. For example, item #5, “Intended Improvement,” concerns the aim of the improvement intervention being reported (shorter patient waiting times, or a consistent increase in hand-washing, for example), and the events and thinking that triggered the decision to put the change into effect. In contrast, item #6, “Study Question,” concerns what a study of the improvement was designed to learn (whether the intervention worked, and context factors that enabled or resisted the change, for example).

How is SQUIRE being used?
Several journals have formally adopted the use of SQUIRE as part of their editorial policy; these journals are listed on the SQUIRE website: http://squire-statement.org/resources/journals. The guidelines are also being used currently by several funding agencies in evaluating the potential of proposed improvement programs, and as a teaching resource at national meetings and in graduate and other education programs. EQUATOR, an international organization that supports the use of reporting guidelines in biomedical publication, provides access to SQUIRE on its website (http://www.equator-network.org/reporting-guidelines/squire/).

What are the future plans for SQUIRE?
In the few years since the SQUIRE guidelines were published, the concepts and methods of the science of improvement have developed rapidly; moreover, authors and editors, peer reviewers and researchers now have considerable experience in using SQUIRE as they make and study improvements in healthcare delivery. Drawing on this experience, the SQUIRE guidelines are now being revised, with the goal of releasing the next version, SQUIRE 2.0, within a year or two. Among the changes likely to be included are greater attention to the use of theory in planning and executing improvement projects; clearer and more explicit concern with the role of context; more accurate, complete, and useful description of improvement interventions; and wider, more appropriate use of analytic methods that reflect the time-dependence of improvement, including statistical process control and similar time-series techniques⁶.

Download here the SQUIRE guidelines

Notes

Disclosure of potential conflicts of interest
Dr. Davidoff reports that he has received a stipend from a grant which funds the revision of the SQUIRE guidelines. Receipt of this stipend is not related in any way to the future use of these guidelines by authors, editors, or any other persons.

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