|Home | About | Journals | Submit | Contact Us | Français|
Collaborative approaches to writing provide a context for undertaking this difficult work, and publication guidelines provide standards for rigorous and useful reports
Research on healthcare improvement is incomplete until it has been published. Improvement science is now a central component of healthcare. Patients should be able to expect continuous improvement of the care they receive. Systems of care increasingly focus on efficient and effective delivery of care. To these ends, it can be argued that those who engage in improvement have a professional obligation to report their methods and results.
Improving healthcare requires precious resources—time and money. Health systems can not afford the duplication and waste that occurs when others must replicate knowledge independently. Many colleagues regularly publish their improvement innovations in this and other journals. But it is appropriate to explore the challenges as well as the opportunities for a wider commitment to publication by improvement experts.1,2
First, improvement professionals often consider their work too local or idiosyncratic to merit generalisation to wider settings, even questioning whether a local project could be replicated in other settings. Second, busy clinicians and managers find they simply cannot create time to write. One perception is they have more compelling tasks at hand—providing care and improving their own patient care setting. They often see writing effectively as the work of others. Third, although scholarly publication is the task of academics, it is ironic that publication of innovative improvement is occasionally undervalued in academic settings. Some in academe have considered improvement research less reliable and scholarly than, for example, randomised controlled trials. Fourth, some healthcare institutions have made approval of improvement projects by ethics committees sufficiently daunting that the absence of human subjects or ethics committee approval has sometimes stood in the way of submission for publication.3 Lastly, editors of many scholarly journals are unreceptive to results of successful improvement initiatives. Similarly, reviewers frequently pronounce a paper insufficiently rigorous, too qualitative or simply unscientific. In this regard, however, guidelines are available and continually evolving. They offer frameworks on which improvement scholars and editors can agree that ensure that the published work is sound.1,4,5
Publication is not the exclusive domain of academics. When a new effective treatment is discovered, it is considered unprofessional, if not unethical, not to report that evidence for better treatment of patients. In the same regard, if a particular practice can make care more effective, efficient, equitable, safer, timely or more patient centred, it is a professional obligation that it is reported and widely implemented. What are effective strategies to assure that publication becomes part of the work of improvement? What might be learned from those who have consistently and successfully published their work?
First, one approach has been to develop a “writing collaborative” together with colleagues. To support writing and hasten publication of effective improvement work, we have tested such a strategy at the conclusion of a recent initiative designed to improve chronic illness care in academic settings,6 and have found that groups of improvement experts who meet regularly to share their writing readily progress to successful development of publishable papers. Early on, guidance was provided across the initiative for the submission of applications to institutional review boards at the various sites. When improvement results were aggregated, participants met to share their writing at monthly meetings, either by teleconference or in person. Each participant was expected to present work at these sessions regardless of its stage of development. The first task was simply to develop a descriptive working title. Next, drafting an abstract, even if it was incomplete, was often helpful. As drafts advanced through various stages of development to more polished manuscripts, they were repeatedly presented for review and comment by members of the writing group; using publications guidelines was also helpful. The success of the writing collaborative depended heavily on those who provided careful and extensive criticism in a supportive context.
Second, the review of journal articles for publication is predicated on a classical improvement strategy. New authors can expect that journal reviewers will be exhaustively critical. Reviewers' comments are intended to improve the science, writing and presentation of the work. An author must be prepared for extensive criticism and realise that this is intended to present their work in the best possible form. When responding to reviews, authors should feel free to communicate with editors and reviewers. Editors expect to be engaged by authors. To the new author the review and editorial process often seems to be dogmatic and hierarchical. In fact, publication is at its heart the work of a scholarly community.
Third, improvement experts might consider becoming a journal reviewer. By offering an editor one's area of expertise an improvement scholar becomes part of the writing and scholarly community.
Fourth, as noted above, several publication guidelines have been promulgated for reporting improvement studies and discoveries.1,4,5 Their wider adoption will support predictable rigour and utility in improvement reports. They remind the author that if the outcomes of improvement work are not well supported by evidence they must be questioned and improved. Authors miss an opportunity when they do not make use of guidelines, which provide a shared set of standards that are increasingly the result of consensus between editors and improvement scholars.
Finally, one should consider writing every day. Some have advised sitting down and writing as little as 15 minutes a day. If one waits until hours can be set aside for the task, one rarely starts. It is time to start.