HiQuiPs: Preparing a QI Manuscript – the SQUIRE 2.0 Guidelines

In Education & Quality Improvement, HiQuiPs by Shawn.MondouxLeave a Comment

You are planning to conduct a quality improvement project and your project supervisor has advocated that you download a copy of the SQUIRE 2.0 QI reporting guidelines before you begin.  This is confusing, as it seemed to you that reporting guidelines governed how a manuscript should be drafted rather than how a project should be conducted.   You decide to take a deeper dive into the SQUIRE 2.0 guidelines.

Introduction: Guidelines for Conducting Research

An essential part of academic medicine and quality improvement is the ability to disseminate the process or results of an intervention.  This is true in both traditional medical research and quality improvement.  Neophyte researchers often begin to address the elements of the manuscript after the clinical experimentation has taken place.  Trained researchers consult writing guidelines as they shape their experimentation to increase the fluidity between experimentation and writing phases.  Experienced researchers have often integrated these processes so as to see, from the outside, little demarcation between experimentation and writing.  As the field of Quality Improvement and Patient Safety (QIPS) remains young, it would be useful to describe how the integration of guidelines in scientific writing will inform and advance publishing in quality improvement.

Medical research is often categorized into distinct groupings based on methodology.  Each research type (eg. randomized trial,​1​ observational study,​2​ systematic review,​3​ etc.) has an accompanying reporting guideline. These documents lay out best practices for publishing manuscripts.  The majority of these guidelines may be found on the EQUATOR (Enhancing the QUAlity and transparency Of health Research) network website.

These guidelines are designed, according to the EQUATOR network, to ensure that a manuscript may be:

  • Understood by a reader,
  • Replicated by a researcher,
  • Used by a doctor to make a clinical decision, and
  • Included in a systematic review.

The SQUIRE guidelines

The SQUIRE guidelines are reporting guidelines dedicated to quality improvement.​4​  These guidelines (commonly referred to as SQUIRE 2.0) were published in 2015 as a revision to the first iteration which was published in 2008.  SQUIRE maintains its own website where authors may find the reporting guidelines in addition to an array of files and tools which are intended to help authors craft a QIPS manuscript which is adherent to the reporting standard.

Figure 1: The Squire logo

When should I incorporate SQUIRE into my manuscript writing?

As was mentioned in the introduction, more experienced QIPS authors incorporate SQUIRE 2.0 guidelines during the inception phase of the project. This is because SQUIRE 2.0 is more than a guide on “how to write a QIPS manuscript;” it’s a checklist that encourages authors to think, write and measure a variety of elements that are essential the reporting standard.  The SQUIRE 2.0 guidelines may act as a roadmap for the research team, coaxing the group to address and answer difficult questions that would increase the robustness of the improvement work. 

For example, the SQUIRE 2.0 guidelines ask the authors to explicitly state the aim of their improvement work.  In many cases, this step can be overlooked in improvement teams where all members agree that the intervention is a good idea for different reasons and aims.  Moreover, the SQUIRE 2.0 guidelines call for the intentional use of a family of measures as well as their rationale.  This means the inclusion of outcome, process and balancing measures and the justification for each.  This approach is not typical of more established research work, and may otherwise be omitted by even experienced QIPS research teams.

It is perhaps best to use the SQUIRE guidelines for the drafting of the research protocol at the outset of the project.  This is advisable for 2 reasons:  (1)  It frames the entirety of the project through a QI lens and engages team members in important discussions around the aims and the measures to be used from the inception of the project, and (2) It supports the claims, when applying to research ethics boards, that this work is QI both in ideals and in methods. 

Okay, but do I NEED to follow the SQUIRE 2.0 guidelines?

You do not.  Although SQUIRE represents best practices for publishing in QI and likely yield the most consumable and “spreadable” manuscript, most quality improvement articles that are featured in prominent journals do not yet follow the SQUIRE 2.0 guidelines.  BMJ Quality and Safety, for example, allows authors to submit both Original Research (which should follow the respective reporting standard) and Quality Improvement Reports (which are to follow the SQUIRE 2.0 guidelines). This represents an acknowledgement that a significant number of research interventions that use other methodologies (e.g. randomized trials with CONSORT guidelines,​1​ observational trials with STROBE guidelines​2​) still may have important findings that should be relayed to a larger audience. Despite the fact that CONSORT and STROBE are not primarily designed for QI, the clear adherence to their tenets and their incorporation into a research team’s processes typically generates a high-quality manuscript.

The trouble is when research teams do not incorporate the tenants of any reporting guideline and then look to “adapt” a manuscript, after the intervention has been completed, to suit the requirements of a reporting guideline.  This generally leads to clear gaps in adherence to the reporting standard.  These are most often noticed by editorial teams and become difficult limitations to circumvent. 

Summing up: guidelines for more than just writing

In the end, it turns out the reporting standards are the result of the combined knowledge of individuals with significant expertise in writing manuscripts and conducting projects of a specific subtype.  Although they are meant to guide writing, they are often insightful documents that may drive a research project from its inception, long before a manuscript is ever drafted.  We would encourage all readers to incorporate these reporting guidelines into the foundational documents and guidance of any research project.

This post was copyedited by Matthew Hacker Teper (@matthackerteper)

**UPDATE (November 2020): The HiQuiPs Team is looking for your feedback! Please take 1 minute to answer these three questions – we appreciate the support!**

References

  1. 1.
    Schulz K, Altman D, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med. 2010;152(11):726-732. doi:10.7326/0003-4819-152-11-201006010-00232
  2. 2.
    von E, Altman D, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495-1499. doi:10.1016/j.ijsu.2014.07.013
  3. 3.
    Moher D, Liberati A, Tetzlaff J, Altman D, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
  4. 4.
    Ogrinc G, Davies L, Goodman D, Batalden P, Davidoff F, Stevens D. Squire 2.0 (Standards for Quality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process. Am J Crit Care. 2015;24(6):466-473. doi:10.4037/ajcc2015455

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Shawn.Mondoux

Shawn.Mondoux

Dr. Shawn Mondoux is an emergency physician at Hamilton Health Sciences (HHS) and faculty at McMaster University in Hamilton, Ontario. He obtained a masters of Quality Improvement and Patients Safety (QIPS) at the University of Toronto and serves as QI advisor to all projects within the ED. He has a strong interest in clinical QI work as well as the education of PGME learners in QI principles.
Ahmed Taher

Ahmed Taher

Ahmed is an Emergency Physician at University Health Network and Mackenzie Health in Toronto. He completed the Toronto FRCPC Emergency program, and a Masters of Public Health program at Johns Hopkins Bloomberg School of Public Health with certificates in Quality Improvement & Patient Safety, as well as Public Health Informatics.
Ahmed Taher
- 1 week ago