Standards for QUality Improvement Reporting Excellence 2.0: revised publication guidelines from a detailed consensus process.

Since the publication of Standards for QUality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of three key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Republished: Key characteristics of successful quality improvement curricula in physician education: a realist review.

PURPOSE: Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. METHOD: Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. RESULTS: Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. CONCLUSIONS: This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.

Use of a glucose management service improves glycemic control following vascular surgery: an interrupted time-series study.

BACKGROUND: The optimal method for obtaining good blood glucose control in noncritically ill patients undergoing peripheral vascular surgery remains a topic of debate for surgeons, endocrinologists, and others involved in the care of patients with peripheral arterial disease and diabetes. A prospective trial was performed to evaluate the impact of routine use of a glucose management service (GMS) on glycemic control within 24 hours of lower-extremity revascularization (LER). METHODS: In an interrupted time-series design (May 1, 2011-April 30, 2012), surgeon-directed diabetic care (Baseline phase) to routine GMS involvement (Intervention phase) was compared following LER. GMS assumed responsibility for glucose management through discharge. The main outcome measure was glycemic control, assessed by (1) mean hospitalization glucose and (2) the percentage of recorded glucose values within target range. Statistical process control charts were used to assess the impact of the intervention. RESULTS: Clinically important differences in patient demographics were noted between groups; the 19 patients in the Intervention arm had worse peripheral vascular disease than the 19 patients in the Baseline arm (74% critical limb ischemia versus 58%; p = .63). Routine use of GMS significantly reduced mean hospitalization glucose (191 mg/dL Baseline versus 150 mg/dL Intervention, p < .001). Further, the proportion of glucose values in target range increased (48% Baseline versus 78% Intervention, p = .05). Following removal of GMS involvement, measures of glycemic control did not significantly decrease for the 19 postintervention patients. CONCLUSIONS: Routine involvement of GMS improved glycemic control in patients undergoing LER. Future work is needed to examine the impact of improved glycemic control on clinical outcomes following LER.

Key Strategies to Publishing Your Quality Improvement Work.

BACKGROUND: Improving quality and safety is a goal in health care, and sharing quality improvement (QI) work with internal and external audiences is key to spreading knowledge and ideas for change. Peer-reviewed journals are interested in manuscripts reporting QI work. METHODOLOGY: Although QI work is methodologically different from traditionally published research articles, it can be publishable if conducted in a way that is scholarly and well-planned. The authors suggest that key strategies to producing publishable, scholarly improvement work exist within two broad categories: rigorous work and compelling writing. Rigorous improvement work includes the following four key components: (1) understanding baseline processes, (2) developing a solid methodology and measurement plan, (3) analyzing and describing context, and (4) clearly explaining the intervention. Creating compelling writing includes clear team expectations that are defined early in the process, including authorship and division of the work. The team should identify a journal early in the process and follow a clear plan for team writing that includes an outline and frequent feedback. CONCLUSION: Elements of rigorous QI work and compelling writing align to develop strong material for publishing scholarly QI work.

Quality initiatives: statistical control charts: simplifying the analysis of data for quality improvement.

Quality improvement (QI) projects are an integral part of today's radiology practice, helping identify opportunities for improving outcomes by refining work processes. QI projects are typically driven by outcome measures, but the data can be difficult to interpret: The numbers tend to fluctuate even before a process is altered, and after a QI intervention takes place, it may be even more difficult to determine the cause of such vacillations. Control chart analysis helps the QI project team identify variations that should be targeted for intervention and avoid tampering in processes in which variation is random or harmless. Statistical control charts make it possible to distinguish among random variation or noise in the data, outlying tendencies that should be targeted for future intervention, and changes that signify the success of previous intervention. The data on control charts are plotted over time and integrated with various graphic devices that represent statistical reasoning (eg, control limits) to allow visualization of the intensity and overall effect-negative or positive-of variability. Even when variability has no substantial negative effect, appropriate intervention based on the results of control chart analysis can help increase the efficiency of a process by optimizing the central tendency of the outcome measure. Different types of control charts may be used to analyze the same outcome dataset: For example, paired charts of individual values (x) and the moving range (mR) allow robust and reliable analyses of most types of data from radiology QI projects. Many spreadsheet programs and templates are available for use in creating x-mR charts and other types of control charts.

Designing education to improve care.

BACKGROUND: Educators in all health care disciplines are increasingly aware of the importance and value of teaching improvement as an integral part of health professional development. Although faculty and learners can often identify needed changes in the clinical setting, many educators are not sure how to teach the improvement principles and methods needed to achieve and sustain those changes. DEFINING AND DEVELOPING COMPETENCY IN QI: Five developmental levels apply to physicians, nurses, and other members of an interprofessional quality improvement (QI) team: novice, advanced beginner, competent, proficient, and expert. For example, the expert develops a vast repertoire of skills and a capacity for situational discrimination, performs tasks on a more intuitive level, and recognizes and immediately addresses essential problems. Improvement is an action, and learning about improvement must be action based. Certain skills and knowledge are required at each stage in this learning process so that students in the health professions achieve competence in QI before entering practice. GENERAL PRINCIPLES FOR EDUCATIONAL EXPERIENCES IN HEALTH CARE IMPROVEMENT: Four principles, which apply at any developmental level, can help answer educators' questions about where to start: (1) The Learning Experience Should Be a Combination of Didactic and Project-Based Work; (2) Link with Health System Improvement Efforts; (3) Assess Education Outcomes; and (4) Role Model QI in Educational Processes. CONCLUSION: As educators teach future health professionals about improving care, the dissemination of exemplary models and emerging best practices will be increasingly important. Sustainability of improvements in patient outcomes will be dependent on both the value systems and skills of health professionals entering practice.

Adapting SQUIRE 2.0 to Create a Quality Improvement Evidence-Based Medicine Critical Appraisal Tool (QI-EBM-CAT) for Graduate Medical Education Trainees.

Background: Evidence-based medicine (EBM) has long been taught to physician trainees for critical appraisal of research manuscripts. There is no parallel or similar framework to guide trainees in the appraisal of quality improvement (QI) literature. Objective: To adapt existing guidelines of QI manuscript reporting into an educational QI-EBM appraisal tool to help residents distinguish research and QI manuscripts, assess QI designs and methodologies, and evaluate QI manuscripts' strengths and weaknesses. Methods: Between 2018 and 2021, we developed a QI-EBM critical appraisal tool (QI-EBM-CAT) and performed 3 plan-do-study-act cycles to refine the tool based on JAMA and SQUIRE 2.0 guidelines. We then surveyed residents regarding the usefulness of the tool and their confidence in evaluating QI manuscripts before and after completing a QI-EBM workshop using the QI appraisal tool. Results: Sixty-six of 74 internal medicine postgraduate year (PGY)-1 to PGY-3 residents (89.2%) completed the workshop and assessment surveys in 2021. The workshop was found to be moderately to very useful by 85.1% (63 of 74) of residents as a framework for QI manuscript critical analysis. The summary confidence score in QI manuscript critical appraisal improved from a 64% rating of moderately to very confident in the pre-period to 94.6% in the post-period (P<.001) with statistical improvements in all 5 confidence areas assessed (P<.001). Conclusions: The QI-EBM-CAT, designed to teach residents how to critically assess QI manuscripts using EBM principles, resulted in subjective improvements in confidence of QI manuscript analysis.

Measuring and publishing quality improvement.

Misalignment of measures, measurement and analysis with the goals and methods of quality improvement efforts in healthcare may create confusion and decrease effectiveness. In healthcare, measurement is used for accountability, research, and quality improvement, so distinguishing between these is an important first step. Using a case vignette, this paper focuses on using measurement for improvement to gain insight into the dynamic nature of healthcare systems and to assess the impact of interventions. This involves an understanding of the variation in the data over time. Statistical process control (SPC) charting is an effective and powerful analysis tool for this. SPC provides ongoing assessment of system functioning and enables an improvement team to assess the impact of its own interventions and external forces on the system. Once improvement work is completed, the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines is a valuable tool to describe the rationale, context, and study of the interventions. SQUIRE can be used to plan improvement work as well as structure a manuscript for publication in peer-reviewed journals.

The state of nutrition in medical education in the United States.

Despite the significant impact diet has on health, there is minimal nutrition training for medical students. This review summarizes published nutrition learning experiences in US medical schools and makes recommendations accordingly. Of 902 articles, 29 met inclusion criteria, describing 30 learning experiences. Nutrition learning experiences were described as integrated curricula or courses (n = 10, 33%), sessions (n = 17, 57%), or electives (n = 3, 10%). There was heterogeneity in the teaching and assessment methods utilized. The most common was lecture (n = 21, 70%), often assessed through pre- and/or postsurveys (n = 19, 79%). Six studies (26%) provided experience outcomes through objective measures, such as exam or standardized patient experience scores, after the nutrition learning experience. This review revealed sparse and inconsistent data on nutrition learning experiences. However, based on the extant literature, medical schools should build formal nutrition objectives, identify faculty and physician leadership in nutrition education, utilize preexisting resources, and create nutrition learning experiences that can be applied to clinical practice.

Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?

In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.

Building the Bridge to Quality: An Urgent Call to Integrate Quality Improvement and Patient Safety Education With Clinical Care.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.

Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project.

In 2005, draft guidelines were published for reporting studies of quality improvement as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as Standards for QUality Improvement Reporting Excellence (SQUIRE). This narrative progress report summarizes the special features of improvement that are reflected in SQUIRE and describes major differences between SQUIRE and the initial draft guidelines. It also explains the development process, which included formulation of responses to informal feedback, written commentaries, and input from publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programs; and a meeting of stakeholders for critical review of the guidelines' content and wording, followed by commentary on sequential versions from an expert consultant group. Finally, the report discusses limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions under development; and plans for dissemination, testing, and further development of SQUIRE.

A standardized curriculum to introduce novice health professional students to practice-based learning and improvement: a multi-institutional pilot study.

BACKGROUND: Practice-based learning and improvement (PBLI) combines the science of continuous quality improvement with the pragmatics of day-to-day clinical care delivery. PBLI is a core-learning domain in nursing and medical education. We developed a workbook-based, project-focused curriculum to teach PBLI to novice health professional students. PURPOSE: Evaluate the efficacy of a standardized curriculum to teach PBLI. DESIGN: Nonrandomized, controlled trial with medical and nursing students from 3 institutions. METHODS: Faculty used the workbook to facilitate completion of an improvement project with 16 participants. Both participants and controls (N = 15) completed instruments to measure PBLI knowledge and self-efficacy. Participants also completed a satisfaction survey and presented project posters at a national conference. RESULTS: There was no significant difference in PBLI knowledge between groups. Self-efficacy of participants was higher than that of controls in identifying best practice, identifying measures, identifying successful local improvement work, implementing a structured change plan, and using Plan-Do-Study-Act methodology. Participant satisfaction with the curriculum was high. CONCLUSION: Although PBLI knowledge was similar between groups, participants had higher self-efficacy and confidently disseminated their findings via formal poster presentation. This pilot study suggests that using a workbook-based, project-focused approach may be effective in teaching PBLI to novice health professional students.

Realist evaluation as a framework for the assessment of teaching about the improvement of care.

Health professions education researchers continually search for tools to measure, evaluate, and disseminate the findings from educational interventions. Clinical teaching, particularly teaching about the improvement of care and systems, is marked by complexity and is invariably influenced by the context into which the intervention is placed. The traditional research framework states that interventions should be adjudicated through a yes or no decision to determine effectiveness. In reality, educational interventions and the study of the interventions rarely succumb to such a simple yes or no question. The realist evaluation framework from Pawson and Tilley provides an explanatory model that links the context, mechanisms, and outcome patterns that are discovered during implementation of a project. This article describes the unique qualities of the realist evaluation, the basic components and steps in a realist evaluation, and an example that uses this technique to evaluate teaching about improvement of care in a clinical setting.

Health Systems Science: The "Broccoli" of Undergraduate Medical Education.

Health system leaders are calling for reform of medical education programs to meet evolving needs of health systems. U.S. medical schools have initiated innovative curricula related to health systems science (HSS), which includes competencies in value-based care, population health, system improvement, interprofessional collaboration, and systems thinking. Successful implementation of HSS curricula is challenging because of the necessity for new curricular methods, assessments, and educators and for resource allocation. Perhaps most notable of these challenges, however, is students' mixed receptivity. Although many students are fully engaged, others are dissatisfied with curricular time dedicated to competencies not perceived as high yield. HSS learning can be viewed as "broccoli"-students may realize it is good for them in the long term, but it may not be palatable in the moment. Further analysis is necessary for accelerating change both locally and nationally.With over 11 years of experience in global HSS curricular reform in 2 medical schools and informed by the curricular implementation "performance gap," the authors explore student receptivity challenges, including marginalization of HSS coursework, infancy of the HSS field, relative nascence of curricula and educators, heterogeneity of pedagogies, tensions in students' perceptions of their professional role, and culture of HSS integration. The authors call for the reexamination of 5 issues influencing HSS receptivity: student recruitment processes, faculty development, building an HSS academic "home," evaluation metrics, and transparent collaboration between medical schools. To fulfill the social obligation of meeting patients' needs, educators must seek a shared understanding of underlying challenges of HSS innovations.

What Do I Do When Something Goes Wrong? Teaching Medical Students to Identify, Understand, and Engage in Reporting Medical Errors.

PROBLEM: Identifying and processing medical errors are overlooked components of undergraduate medical education. Organizations and leaders advocate teaching medical students about patient safety and medical error, yet few feasible examples demonstrate how this teaching should occur. To provide students with familiarity in identifying, reporting, and analyzing medical errors, the authors developed the interactive patient safety reporting curriculum (PSRC), requiring clinical students to engage intellectually and emotionally with personally experienced events in which the safety of one of their patients was compromised. APPROACH: In 2015, the authors incorporated the PSRC into the third-year internal medicine clerkship. Students completed a structured written report, analyzing a patient safety incident they experienced. The report focused on severity of outcome, root cause(s) analysis, system-based prevention, and personal reflection. The report was bookended by 2 interactive, case-based sessions led by faculty with expertise in patient safety, quality improvement, and medical errors. OUTCOMES: Students accurately analyzed the severity of the outcome, and their reports directly led to 2 formal root cause analyses and 4 system-based improvements. NEXT STEPS: The time- and resource-efficient PSRC allows students to apply patient safety knowledge to a medical error they experienced in a way that can directly affect care delivery. This model-interactive learning sessions coupled with engaging in a personally experienced case-can be implemented in various settings. Educators seeking to use student-experienced events for learning should not discount the emotional effects of those events on medical students.

A 4-Year Integrated Nutrition Curriculum for Medical Student Education.

While poor diet is the one of the primary contributors to death and disability in the USA, formal nutrition education in medical schools across the nation remains sparse. As it stands, few medical schools have formally incorporated nutrition education, and fewer still have integrated nutrition into the entire length of their 4-year curriculum. We describe how a new, formally integrated, 4-year nutrition curriculum was developed and is being implemented in a US medical school, and how this program will evolve as part of a twenty-first century medical school education.