publishing quality improvement (qi) projects

Publishing QI Projects

R Robinson, MD, FACP

Hospitalist

Associate Professor of Clinical Medicine

Objectives

• Understand barriers to QI publication

• Review SQUIRE Guidelines

• Understand QI publishing process

What is QI?

Quality Improvement/Assurance (QI/QA) is a

systematic, data-guided activity designed to bring

about immediate improvement in health care,

education or other service delivery in a local

setting.

Ann Intern Med 2007;146:666-73.

Healthcare needs QI

QI Methods are Tools

• TQM

• Six Sigma

QI Plan

Do

Study

Act

QI is required for many physicians

QI is required for many physicians

Quality bonuses in 39% of practices in 2012/2013 Merritt Hawkins Survey

QI Data is Rarely Published

Barriers to QI publication• Publication biases

• Permission to publish

• Difficult to write about

• Incentive Alignment

Publication Biases

Leading Journals – QI articles

57 / 65,592

0.08% QI related

7 / 70,579

0.01% QI related

Diabetes

0

10000

20000

30000

Diabetes QI Diabetes

Diabetes

99%294, 1%

Diabetes Diabetes QI

2013 Data

Permission to publish

What kind of data?

• Process

• Efficiency

• Outcomes

• Costs

What kind of data?

• Process

• Efficiency

• Outcomes

• Costs

• Trade secrets

• Financial data

Risks of publication

• Competition

▫ Reproducible methods/processes

▫ Institutional weaknesses

• Risk management

▫ Outcomes

Permission to publish

• Define publication as an objective

• Meet with institutional leadership

▫ What will be published?

▫ What measures will be published?

▫ Will negative results be published?

• Secure written permission to publish

Writing about QI

Research vs. QIResearch QI

• Knowledge

• Linear

• Quantitative

• Fixed protocol

• Generalizable

• Controlled Experiment

• Process

• Non-linear

• Qualitative

• Malleable

• Localized

• Quasi-Experimental

Research Context

Project Fixed

Adaptable

QI Context

Project

Fixed

Adaptable

SQUIRE Guidelines• Standards for QUality Improvement Reporting Excellence

• www.squire-statement.org

• Framework for reporting QI projects

▫ Published in 2008

▫ Required by many journals that publish QI

SQUIRE Guidelines - Introduction

• Background knowledge

• Local problem

• Intended improvement

• Study question(s)

SQUIRE Guidelines - Methods

• Ethical issues

• Setting

• Planning the intervention

• Planning the study of the intervention

• Methods of evaluation

• Analysis

SQUIRE Guidelines - Results

• Outcomes

SQUIRE Guidelines - Discussion

• Summary

• Relation to other evidence

• Limitations (generalizability)

• Interpretation

• Conclusions

Incentive Alignment

Incentives to publish research

• Promotion

• Tenure

• Research funding

• Prestige

▫ Journal selection / Impact factor

Incentives to publish QI

• Promotion (?)

• Tenure (?)

• Research funding

• Prestige (?)

Academic careers

Incentives for QI work• Solving local problems

• Career advancement▫ MOC▫ Hospital / Institutional leadership

• Financial incentives

Quality bonuses in 39% of practices in 2012/2013 Merritt Hawkins Survey

Planning a project

Set Publication Goals Early

Problem

No Publication

Publication

QI Publication Pathway

Protocol IRB PDSA Publish

Develop QI project protocolEssential for submission to IRB!

Protocol Development

• Define problem(s)

• Define process

• Define measures

Protocol Development Assistance

• SIU Center for Clinical Research

• Vice Chair for Research & Scholarship

▫ Dr Jakoby

• SIU Healthcare Quality & Safety

▫ Dr Sattovia

SIU Center for Clinical Research

• Administration & Financial Management

• Clinical Research Operations

• Population Health Science

• Research & Development

• Statistics

QI Publication Pathway

Protocol IRB PDSA Publish

Institutional Review Board

IRB approval

• Many journals require approval for publication

• Visit SCHRIS website and submit the “Determination of Human Subject Research” form

IRB approval

• Many journals require approval for publication

IRB approval

• Many journals require approval for publication

• Visit SCHRIS website and submit the “Determination of Human Subject Research” form

• Submit the appropriate SCHRIS application

Types of IRB application

• Full application

• Expedited

▫ Identifiable data, no or minimal risk to subject

• Exempt

▫ Anonymous data, no risk to subject

Types of IRB application

• Full application

• Expedited

• Exempt Most QI Projects

QI Publication Pathway

Protocol IRB PDSA Publish

Plan

Do

Study

Act

QI Publication Pathway

Protocol IRB PDSA Publish

Where to publish QI data

Journal Article

Poster

Presentation

Abstract

Choosing a Journal

Leading Journals – QI articles

57 / 65,592

0.08% QI related

IF 27.75

7 / 70,579

0.01% QI related

IF 47.05

Leading Journals – QI articles

57 / 65,592

0.08% QI related

7 / 70,579

0.01% QI related

Pick a journal that routinely

publishes QI articles

Leading QI Journals

IF 3.281 IF 1.417 IF 0.30IF 5.4IF 16.7

QI Publication Pathway

Protocol IRB PDSA Publish

Writing your article

• Choose journal

• Read and understand submission criteria

▫ SQUIRE

▫ IRB

• Write article

Areas for careful attention

• Methods

▫ Setting

▫ Measures

▫ Analysis

• Discussion

▫ Limitations (generalizability)

Summary• QI projects are publishable as research

• Publishing QI can be challenging

• QI Publication requires careful planning▫ IRB▫ Generalizability