With the growing interest in generating and disseminating knowledge to improve health-care quality, CJNR is pleased to announce a new section titled Quality Improvement Studies. This section will focus on advancing practice-based nursing scholarship, and articles may cover any aspect of clinical or therapeutic care or service improvements in any practice setting.
Policy
CJNR has adapted the BMJ Quality and Safety policy on quality improvement reports that are considered to be exempt from ethics review1 and recommends the use of SQUIRE (see Appendix 1)2 for writing up a quality improvement study.
CJNR will accept quality improvement manuscripts that have received either ethics approval by a Research Ethics Board (REB)/Institutional Research Board (REB) or approval by an institutional review committee.
REB/IRB-Approved Quality Improvement Projects
A statement that the project has been approved by the REB/IRB of the appropriate institution or organization must be included in the text of your manuscript. Also, a copy of the REB/IRB approval letter must accompany your submission.
Institutionally Approved Quality Improvement Projects
A statement to the effect that the study met criteria for exemption from an appropriate review board according to institutional policy (e.g., because the work was deemed an important improvement activity and did not fall into the category of human subjects research)
must be included in the text of your manuscript. Also, a copy of the REB/IRB exempt letter must accompany your submission.
Sample statements:
- For main text of manuscript: “According to the policy activities that constitute research at the [name of institution/organization], this work met criteria for operational improvement activities that are exempt from ethics review[JB1] .”
- For study approval section of submission template: “[name of institution/organization] uses the following criteria for determining whether improvement activities require ethics review”:
Policy criterion: “The work is primarily intended to improve local care, not to produce generalizable knowledge in a field of inquiry.”
Example: “The work reported here meets this criterion because hand hygiene is a universally recommended practice. We sought only to evaluate the improvements in compliance with hand hygiene as a result of auditing and feedback of compliance rates to hospital staff.”
Differentiating Quality Improvement From Research
Two key criteria can be used to distinguish between quality improvement and research.2,3,4
- The express purpose of the project and who will benefit from it: The purpose of quality improvement is to improve care for the population served by a specific health-care facility or to share lessons learned from implementation. The purpose of research, in contrast, is to generate knowledge about a new strategy or innovation that produces specific outcomes that may be applied generally.4
- The risks and burdens borne by those participating in the project: If an intervention imposes risks or burdens beyond the standard of practice to make the results generalizable, it needs to be reviewed and regulated as research.
Format
The manuscript should be a maximum of 10 double-spaced pages, including references (up to 20) and tables/figures (up to 2), and should address the relevant sections of the rating form. The abstract should be a maximum of 200 words. The style guide to be followed is the Publication Manual of the American Psychological Association, 6th Edition.
The presentation of quality improvement articles should adhere to SQUIRE (see Appendix 1)2 and include five sections3:
Introduction
- Provide a brief description of context: relevant details of staff and function of department, team, unit, and patient group.
- Outline the quality improvement or patient safety issue and describe what you sought to achieve.
Methods
- Organize your Methods section in logical or chronological order. For example, it is more logical to describe the improvement or safety effort before the outcome measures.
- Delineate what course of action for the improvement was taken and describe what changes were made, and why, how they were implemented, and who was involved in the change process.
- Delineate the key measures for improvement, including what would constitute improvement in the view of the patient and/or the provider.
- Describe the process of gathering information, including the methods used to assess the improvement or the safety issue.
- Describe your analysis, including the analytical methods and software used.
Results
- Highlight your pertinent findings in an objective manner.
- Report the demographics/characteristics of your population, followed by pertinent findings.
- If you have a substantial amount of qualitative data, report in bullet form or in a table or box and discuss the main points in the text.
Discussion
- Interpret and discuss your findings to illustrate what is important in your improvement or safety efforts and what the reader should do with this information.
- Explain why your findings are important; even negative findings will offer useful information.
- Put your findings in the context of relevant studies. Discuss how your study builds on prior studies and what knowledge it contributes.
Conclusion
- Discuss the implications of your findings in terms of the next steps. Describe what you have learnt and/or achieved and how you will take this forward.
1 BMJ Journals. (2015). BMJ quality and safety: Policy on ethics review for quality improvement reports. Retrieved from[JB2] BMJ April 1 2015 http://qualitysafety.bmj.com
2 Davidoff, F., Batalden, P., Stevens, D., Ogrinc, G., & Mooney, S. (2008). Publication guidelines for quality improvement in health care: Evolution of the SQUIRE project. Annals of Internal Medicine, 149(9), 670–676.
3 Holzmueller, C. G., & Pronovost, P. (2013). Organising a manuscript reporting quality improvement or patient safety research. BMJ Quality and Safety, 22(9), 777–785.
4 Newhouse, R. P., Poe, S., Pettit, J. C., & Rocc, L. (2006). The slippery slope: Differentiating between quality improvement and research. Journal of Nursing Administration, 36(4), 211–219.
Appendix 1 Standards for Quality Improvement Reporting Excellence (SQUIRE)2
Text section |
Section or item description |
Title and abstract |
Did you provide clear and accurate information for finding, indexing, and scanning your article? |
1. Title |
|
2. Abstract |
Summarizes all key information from various sections of the text using the abstract format of the intended publication |
Introduction |
Explains why you undertook this work |
3. Background knowledge |
Provides a brief, non-selective summary of current knowledge of the care problem being addressed and characteristics of organizations in which it occurs |
4. Local problem |
Describes the nature and severity of the specific local problem or system dysfunction that was addressed |
5. Intended improvement |
|
6. Study question |
States the primary improvement-related question and any secondary questions that the study of the intervention was designed to answer |
Methods |
Describes what you did |
7. Ethical issues
|
Describes ethical aspects of implementing and studying the improvement, such as privacy concerns, protection of participants' physical well-being, and potential author conflicts of interest, and how ethical concerns were addressed |
8. Setting
|
Specifies how elements of the environment considered most likely to influence change/improvements at the particular site or sites were identified and characterized |
9. Planning the intervention
|
|
10. Planning the study of the intervention
|
|
11. Methods of evaluation
|
|
12. Analysis
|
|
Results |
What you found |
13. Outcomes |
a.Nature of setting and improvement intervention i.Characterizes elements of setting or settings (e.g., geography, physical resources, organizational culture, history of change efforts) and structures and patterns of care (e.g., staffing, leadership) that provided context for the intervention ii.Outlines the course of the intervention (e.g., sequence of steps, events or phases; type and number of participants at key points), preferably using a timeline diagram or flow chart iii.Documents degree of success in implementing intervention components iv.Describes how and why the initial plan evolved, and the most important lessons learned from that evolution, particularly the effects of internal feedback from tests of change (reflexiveness) b.Changes in processes of care and patient outcomes associated with the intervention v.Presents data on changes observed in the care delivery process vi.Presents data on changes observed in measures of patient outcome (e.g., morbidity, mortality, function, patient/staff satisfaction, service utilization, cost, care disparities) vii.Considers benefits, harms, unexpected results, problems, failures viii.Presents evidence regarding the strength of association between observed changes/improvements and intervention components/contextual factors ix.Includes summary of missing data for intervention and outcomes |
Discussion |
What the findings mean |
14. Summary |
|
15. Relation to other evidence
|
Compares and contrasts your results with those of others, drawing on a broad review of the literature; use of a summary table may be helpful in building on existing evidence |
16. Limitations |
|
17. Interpretation |
|
18. Conclusions |
|
Other information |
Other factors relevant to conducting and interpreting the study |
19. Funding |
Describes funding sources, if any, and role of funding organization in design, implementation, interpretation, and publishing of study |