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Why new guidelines for reporting improvement research? And why now?

Correspondence to:
Dr D P Stevens
Association of American Medical Colleges, 2450 N Street, NW Washington, DC 20037, USA; dstevens{at}aamc.org

Keywords: quality improvement; evidence; publication; guidelines

It is reasonable to ask why QSHC would embark on additional guidelines for reporting improvement research—and why now?¹ Useful and valuable guidelines for quality improvement reports (QIRs) were initially published in our predecessor journal, Quality in Health Care, in 1999,² and reprinted again in QSHC in 2004. The BMJ also adopted this format in 2001.³ QIRs were initially slow to appear, but they have been published recently with increasing regularity in QSHC, particularly since the QIR guidelines were reprinted.

In their paper in this issue of QSHC Davidoff and Batalden emphasize that the proposed new guidelines are not intended to supersede QIRs.¹ Indeed, they are best seen as part of the continuum of improvement scholarship that ranges from individual case reports and QIRs to studies that address complex systems and safety issues.⁴ In their accompanying commentaries, Berwick⁵ and Thomson⁶ serve to expand on this perspective.

Granted, this initiative is in one sense about scholarship and the scholar. But at its core it is about patient care and the patient. The purpose of critical, scholarly investigation in healthcare improvement is to provide the important new knowledge that leads to better, safer care. Moss and Thomson, in framing guidelines for QIRs, put their focus on the patient.² So it should be with this initiative. To that end, the assessment of the impact of these draft guidelines should include their contribution to improvement in patient care.

The authors of the CONSORT guidelines for reporting randomized controlled trials have provided a road map for the refinement of publication guidelines.⁷ They have emphasized that it is an ongoing process, and that important components of the process include transparency, consensus, regular updating to reflect their usefulness, and constant testing to assure that the guidelines that are retained are indeed of demonstrable utility.⁷

By publishing these proposed guidelines,¹ the editors of QSHC commit to several strategies that we believe will contribute value to this consensus project. First, the guidelines are published in this issue as a draft. Accordingly, we invite responses to a questionnaire regarding this draft on our home page (http://www.qshc.com). Secondly, we will commission formal commentaries and editorials in subsequent issues of QSHC that will address key issues surrounding these guidelines. Thirdly, QSHC will road test the guidelines by asking authors, reviewers, and editors to use them in their work with this journal. We will encourage their responses to a brief questionnaire that will be used specifically to assess its utility for authors and reviewers. Fourthly, we plan to hold a consensus meeting in 2006 to foster further discussion and consensus among the broader academic and editorial communities regarding the framework proposed by these authors. Fifthly, a revised version of the guidelines—the product of these extended tests and discussions—will be published in subsequent issues of QSHC, currently planned next for October 2006.

One of Tom Nolan’s basic tenets of improvement is that one must answer the question: "How do we know that a change is an improvement?" His answer is by measurement.⁸ It is clear that the outcomes of this process will challenge our best assessment skills. Here are five suggested outcome measures.

• If crafted well, guidelines will offer better and more explicit guidance for authors and editors.
  
• Their availability should accelerate the appearance of publications of consistently higher value, thereby contributing to what Grove has called "research efficiency".⁹ (On the other side of the ledger, if they add unnecessarily doctrinaire or superfluous tasks, they could conceivably slow innovation.¹⁰)
  
• Their utility should be reflected in more frequent publication of improvement work in higher impact journals.
  
• By extension, guidelines should contribute to better design of studies.
  
• They could conceivably influence granting agencies in their criteria for supporting such research.^8,10
  

There is more at stake here than comprehensive rules for scientific reporting. Hence the need to get it right.

Why new guidelines? And why now? The answer in the largest context is that patient care is not nearly at the level of quality that is possible. The explanations for this gap between knowledge and practice are many and complex,^11,12 and go well beyond medical journals and scientific publications. Nevertheless, these guidelines invite an expanded discussion regarding the important research that can contribute to healthcare quality and patient safety. We at QSHC commit to serve in every way possible to facilitate that discussion.

REFERENCES

1. Davidoff F, Batalden P. Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project, Qual Saf Health Care 2005;14:319–25.[Abstract/Free Full Text]
2. Moss F, Thomson R. A new structure for quality improvement reports. Qual Health Care 1999;8:76.[Medline]
3. Smith R. Quality improvement reports: a new kind of article. BMJ 2000;321:1428.[Free Full Text]
4. Peterson ED. Optimizing the science of quality improvement. JAMA 2005;294:369–71.[Free Full Text]
5. Berwick D. Broadening the view of evidence-based medicine. Qual Saf Health Care 2005;14:000.
6. Thomson R. Consensus publication guidelines: the next step in the science of quality improvement? Qual Saf Health Care 2005;14:000–0.
7. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. Lancet 2001;357:1191–4.[CrossRef][Medline]
8. Langley GJ, Nolan KM, Nolan TW, et al. The improvement guide. San Francisco: Josey-Bass, 1996.
9. Grove AS. Efficiency in the health care industries: a view from the outside. JAMA 2005;294:490–2.[Free Full Text]
10. DeAngelis CD, Drazen JM, Frizelle FA, et al. Is this clinical trial fully registered?—A statement from the International Committee of Medical Journal Editors. N Engl J Med 2005;352:2436–8.[Free Full Text]
11. Institute of Medicine. To err is human: building a safer health care system. Washington, DC: National Academy Press, 1999.
12. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001.

This article has been cited by other articles:

				D P Stevens and B. Andersson-Gare A proposal: publication guidelines for healthcare improvement education reports Qual. Saf. Health Care, December 1, 2007; 16(6): 402 - 402. [Full Text] [PDF]

				D. P Stevens If you haven't published your work, it's time to start Qual. Saf. Health Care, August 1, 2007; 16(4): 242 - 243. [Full Text] [PDF]

				P Pronovost and R Wachter Proposed standards for quality improvement research and publication: one step forward and two steps back. Qual. Saf. Health Care, June 1, 2006; 15(3): 152 - 153. [Full Text] [PDF]

This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this link to a friend Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stevens, D P Search for Related Content PubMed PubMed Citation Articles by Stevens, D P Related Collections Guidelines Quality improvement QSHC Guidelines Related Articles