The SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) Guidelines: A Framework for Designing and Reporting Quality Improvement Studies, Application in Perioperative Care

Key points

The SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guidelines provide a framework around which to construct and report an improvement project.
The guidelines provide a format recognized by mainstream journals for the reporting of quality improvement studies.

Background

As quality improvement (QI) studies have become more widespread and researchers try to get studies published, the need for a structured method of formulating a QI study and reporting the findings has been recognized. The S tandards for QU ality I mprovement R eporting E xcellence (SQUIRE) guidelines were first published in 2008 and were revised to SQUIRE 2.0 in 2015 to reflect the increasing understanding of theories underpinning improvement work, the importance of the local context in which the study is undertaken, and the study of the actual improvement intervention. The 2.0 version of the guidelines was evolved through expert opinion and feedback on the original version and was tested by expert authors who wrote sections of a manuscript using the guidelines. Feedback was provided by biomedical journal authors, resulting in further refinement.

Standardized guidelines and reporting for QI studies serve several purposes:

1.
It helps the author/researcher to think about the structure of the study.
2.
It aims to ensure that all relevant steps are reported so the reader can understand how the study was performed and in what context.
3.
It increases the value of reported QI studies by ensuring reporting is done in a reliable and consistent way.
4.
It provides a format that is recognized by major journals for QI studies.

Journals that use the SQUIRE guidelines include BMJ Quality and Safety , the Journal of the American College of Surgeons , the Joint Commission Journal of Quality and Patient Safety, and BMJ Quality Open . The latter journal provides a good location to publish QI studies. Although the SQUIRE guidelines have facilitated QI reporting and publication, QI studies can still be hard to get published in mainstream journals. Other relevant guidelines such as STROBE ( S trengthening the R eporting of OB servational studies in E pidemiology) for observational studies can be used in addition, if appropriate. An overview of reporting tools including SQUIRE 2.0 and STROBE can be viewed on the EQUATOR ( E nhancing the Q U ality and T ransparency O f health R esearch) website.

The sections of the SQUIRE 2.0 guidelines are divided into the familiar introduction, methods, results, and discussion sections but here are also framed as:

▪
Why did you start?
▪
What did you do?
▪
What did you find?
▪
What does it mean?

The SQUIRE 2.0 checklist contains 18 items ( Box 16.1 ) and researchers should consider all items, but not all may apply and need not be reported.

Box 16.1

From 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 Med Qual. 2015;30(6):543–549.

SQUIRE 2.0 Guidelines Checklist

Title/Abstract
1. Title	Indicate that the manuscript concerns an initiative to improve health care (broadly defined to include the quality, safety, effectiveness, patient-centeredness, timeliness, cost, efficiency, and equity of health care).
2. Abstract	a. Provide adequate information to aid in searching and indexing. b. Summarize all key information from various sections of the text using the abstract format of the intended publication or a structured summary, such as background, local problem, methods, interventions, results, and conclusions.
Introduction	Why did you start?
3. Problem Description	Nature and significance of the local problem
4. Available K nowledge	Summary of what is currently known about the problem, including relevant previous studies
5. Rationale	Informal or formal frameworks, models, concepts, and/or theories used to explain the problem, any reasons or assumptions that were used to develop the intervention(s), and reasons why the intervention(s) was expected to work
6. Specific A ims	Purpose of the project and of this report
Methods	What did you do?
7. Context	Purpose of the project and of this report Contextual elements considered important at the outset of introducing the intervention(s)
8. Intervention	1. Description of the intervention(s) in sufficient detail that others could reproduce it 2. Specifics of the team involved in the work
9. Study of the I ntervention	a. Approach chosen for assessing the impact of the intervention(s) b. Approach used to establish whether the observed outcomes were because of the intervention(s)
10. Measures	1. Measures chosen for studying processes and outcomes of the intervention(s), including rationale for choosing them, their operational definitions, and their validity and reliability 2. Description of the approach to the ongoing assessment of contextual elements that contributed to the success, failure, efficiency, and cost 3. Methods employed for assessing completeness and accuracy of data
11. Analysis	1. Qualitative and quantitative methods used to draw inferences from the data 2. Methods for understanding variation within the data, including the effects of time as a variable
12. Ethical Considerations	Ethical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest
Results	What did you find?
13. Results	a. Initial steps of the intervention(s) and their evolution over time (e.g., timeline diagram, flow chart, or table), including modifications made to the intervention during the project b. Details of the process measures and outcome c. Contextual elements that interacted with the intervention(s) d. Observed associations between outcomes, interventions, and relevant contextual elements e. Unintended consequences such as unexpected benefits, problems, failures, or costs associated with the intervention(s). f. Details about missing data
Discussion	What does it mean?
14. Summary	1. Key findings, including relevance to the rationale and specific aims 2. Particular strengths of the project
15. Interpretation	1. Nature of the association between the intervention(s) and the outcomes 2. Comparison of results with findings from other publications 3. Impact of the project on people and systems 4. Reasons for any differences between observed and anticipated outcomes, including the influence of context 5. Costs and strategic trade-offs, including opportunity costs
16. Limitations	a. Limits to the generalizability of the work b. Factors that might have limited internal validity such as confounding, bias, or imprecision in the design, methods, measurement, or analysis c. Efforts made to minimize and adjust for limitations
17. Conclusions	a. Usefulness of the work b. Sustainability c. Potential for spread to other contexts d. Implications for practice and for further study in the field e. Suggested next steps
Other Information
18. Funding	Sources of funding that supported this work. Role, if any, of the funding organization in the design, implementation, interpretation, and reporting

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Key points

Background

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