Qual Saf Health Care. 2008 October; 17(Suppl_1): i13–i32.
The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration
1Quality Literature Program, The Dartmouth Institute for Health Policy and Clinical Practice; Office of Research and Innovation in Medical Education, Dartmouth Medical School, Hanover, New Hampshire, and White River Junction VA Hospital, White River Junction, Vermont, USA
2Alice Peck Day Memorial Hospital, Lebanon, New Hampshire, USA
3General Internal Medicine; VA National Quality Scholars Program, Birmingham VA Medical Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
4Dartmouth Hitchcock Leadership and Preventive Medicine Residency, Obstetrics and Gynecology and Community and Family Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA
5Institute for Healthcare Improvement (IHI), Harvard Medical School, Boston, Massachusetts, USA
6University of Missouri Health Care, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
7General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
8Departments of Medicine and Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
9VA National Center for Patient Safety Field Office, White River Junction, Vermont, and Dartmouth Medical School, Hanover, New Hampshire, USA
10Field Office of VHA’s National Center for Patient Safety, White River Junction, Vermont, USA
11Rural Ethics Initiatives, Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire, USA
12Departments of Anesthesiology and Critical Care, Surgery, and Health Policy and Management, Center for Innovations in Quality Patient Care, Quality and Safety Research Group, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
13Associates in Process Improvement, Austin, Texas, USA
14VA Greater Los Angeles and University of California Los Angeles, VA HSRD Center of Excellence for the Study of Healthcare Provider Behavior, RAND, VA Greater Los Angeles at Sepulveda, North Hills, California, USA
15Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
16VA National Quality Scholars Fellowship Program, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire, USA
17Institute of Health and Society Medical School, Framlington Place, Newcastle upon Tyne, UK
18Emergency Department, Louis Stokes Cleveland DVAMC, Case Western Reserve University SOM, Cleveland, Ohio, USA
19Inpatient Quality Improvement, Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio, USA
Accepted August 1, 2008.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Reporting guidelines have played an increasingly prominent part in the biomedical literature in the past decade as researchers, editors, reviewers and readers have made serious attempts to strengthen the knowledge base of medicine. Guidelines have been developed for reporting randomised controlled trials (CONSORT),1 2
studies of diagnostic accuracy (STARD),3
epidemiological observational studies (STROBE),4
meta-analysis and systematic reviews of randomised controlled trials (QUOROM),5
meta-analysis and systematic review of observational studies (MOOSE),6
and for other designs and content areas. To date, it has been challenging to publish reports of quality improvement efforts, in part because improvement work involves goals and methods that differ fundamentally from projects that study disease biology. The design, types of interventions, data collection and analysis related to quality improvement projects do not fit easily under existing publication guidelines.
In 1999, the editors of Quality in Health Care
(since renamed Quality and Safety in Health Care
) published guidelines for quality improvement reports (QIR).7
These recommendations were offered as “a means of disseminating good practice” so that practitioners may have the “opportunity to learn from each other as the science of audit and quality improvement matures” (p 76). Since their publication, QIR have been used in over 50 published articles. While the QIR provide an excellent structure for brief reports of improvement work,8
a more detailed and comprehensive set of publication guidelines will be useful for larger and more complex improvement studies.
Quality improvement (QI) is fundamentally a process of change in human behaviour, and is driven largely by experiential learning. As such, the evolution and development of improvement interventions has much in common with changes in social policy and programmes. At the same time, the high stakes of clinical practice demand that we provide the strongest possible evidence on exactly how, and whether, improvement interventions work. This double-barrelled epistemology makes the study and reporting of work in QI extremely challenging, particularly for the many “frontline” healthcare professionals who are implementing improvement programmes outside the academic and publishing communities. Finally, it is possible that many journal editors, peer reviewers, funding agencies and other stakeholders will not be familiar with the methodologies for carrying out, studying and reporting QI projects.9
The lack of consensus-driven guidelines is undoubtedly one factor contributing to the variation in reporting about improvement work and to the variation in completeness and transparency of that reporting. That variation has led to calls for slowing the pace of improvement work, and for increased diligence in applying traditional scientific (that is, experimental) research methods in improvement studies.10
Others have taken just the opposite position, and have called for pushing forward with widespread, short-cycle improvement work, in an effort to develop local learning about what works, in what situations and for whom.11
In our view, this is not an “either/or” proposition; rather, both traditional research and improvement work share a passion for developing and implementing interventions that benefit patients and systems. Research and clinical care delivery will both benefit from more consistent, clear and accurate reporting of improvement work.
Improvement efforts focus primarily on making care better at unique local sites, rather than on generating new, generalisable scientific knowledge. In that respect, most improvement work (like most politics) is local. Despite its local focus, local improvement frequently generate important new generalisable knowledge about systems of care and about how best to change those systems. Whether improvement interventions are small or large, simple or complex, the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines provide an explicit framework for sharing the knowledge acquired by examining those interventions closely, carefully, and in detail.