Overview of some of the challenges publishing the results of a quality improvement project in a peer reviewed academic journal.

1. Publishing QI Projects
R Robinson, MD, FACP
Hospitalist
Associate Professor of Clinical Medicine

2. Objectives
• Understand barriers to QI publication
• Review SQUIRE Guidelines
• Understand QI publishing process

3. 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.

4. Healthcare needs QI

6. QI Methods are Tools
• TQM
• Six Sigma

7. QI Plan
Do
Study
Act

8. QI is required for many physicians

9. QI is required for many physicians
Quality bonuses in 39% of practices in 2012/2013 Merritt Hawkins Survey

10. QI Data is Rarely Published

11. Barriers to QI publication
• Publication biases
• Permission to publish
• Difficult to write about
• Incentive Alignment

12. Publication Biases

13. Leading Journals – QI articles
57 / 65,592
0.08% QI related
7 / 70,579
0.01% QI related

14. Diabetes
0
10000
20000
30000
Diabetes QI Diabetes

15. Diabetes
99% 294, 1%
Diabetes Diabetes QI
2013 Data

16. Permission to publish

17. What kind of data?
• Process
• Efficiency
• Outcomes
• Costs

18. What kind of data?
• Process
• Efficiency
• Outcomes
• Costs
• Trade secrets
• Financial data

21. Risks of publication
• Competition
▫ Reproducible methods/processes
▫ Institutional weaknesses
• Risk management
▫ Outcomes

22. 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

23. Writing about QI

24. Research vs. QI
Research QI
• Knowledge
• Linear
• Quantitative
• Fixed protocol
• Generalizable
• Controlled Experiment
• Process
• Non-linear
• Qualitative
• Malleable
• Localized
• Quasi-Experimental

25. Research
Context
Project
Fixed
Adaptable

26. QI
Context
Project
Fixed
Adaptable

27. 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

28. SQUIRE Guidelines - Introduction
• Background knowledge
• Local problem
• Intended improvement
• Study question(s)

29. SQUIRE Guidelines - Methods
• Ethical issues
• Setting
• Planning the intervention
• Planning the study of the intervention
• Methods of evaluation
• Analysis

30. SQUIRE Guidelines - Results
• Outcomes

31. SQUIRE Guidelines - Discussion
• Summary
• Relation to other evidence
• Limitations (generalizability)
• Interpretation
• Conclusions

32. Incentive Alignment

33. Incentives to publish research
• Promotion
• Tenure
• Research funding
• Prestige
▫ Journal selection / Impact factor

34. Incentives to publish QI
• Promotion (?)
• Tenure (?)
• Research funding
• Prestige (?)
Academic careers

35. Incentives for QI work
• Solving local problems
• Career advancement
▫ MOC
▫ Hospital / Institutional leadership
• Financial incentives

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

37. Planning a project

38. Set Publication Goals Early
Problem
No
Publication
Publication

39. QI Publication Pathway
Protocol IRB PDSA Publish

40. Develop QI project protocol
Essential for submission to IRB!

41. Protocol Development
• Define problem(s)
• Define process
• Define measures

42. Protocol Development Assistance
• SIU Center for Clinical Research
• Vice Chair for Research & Scholarship
▫ Dr Jakoby
• SIU Healthcare Quality & Safety
▫ Dr Sattovia

43. SIU Center for Clinical Research
• Administration & Financial Management
• Clinical Research Operations
• Population Health Science
• Research & Development
• Statistics

44. QI Publication Pathway
Protocol IRB PDSA Publish

45. Institutional Review Board

46. IRB approval
• Many journals require approval for publication
• Visit SCHRIS website and submit the
“Determination of Human Subject Research”
form

47. IRB approval
• Many journals require approval for publication

48. 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

49. Types of IRB application
• Full application
• Expedited
▫ Identifiable data, no or minimal risk to subject
• Exempt
▫ Anonymous data, no risk to subject

50. Types of IRB application
• Full application
• Expedited
• Exempt Most QI Projects

51. QI Publication Pathway
Protocol IRB PDSA Publish

52. Plan
Do
Study
Act

53. QI Publication Pathway
Protocol IRB PDSA Publish

54. Where to publish QI data
Journal
Article
Poster
Presentation
Abstract

55. Choosing a Journal

56. Leading Journals – QI articles
57 / 65,592
0.08% QI related
IF 27.75
7 / 70,579
0.01% QI related
IF 47.05

57. Leading Journals – QI articles
57 / 65,592
0.08% QI related
7 / 70,579
0.01% QI related

58. Pick a journal that routinely
publishes QI articles

59. Leading QI Journals
IF 3.281 IF 1.417 IF 0.30IF 5.4IF 16.7

60. QI Publication Pathway
Protocol IRB PDSA Publish

61. Writing your article
• Choose journal
• Read and understand submission criteria
▫ SQUIRE
▫ IRB
• Write article

62. Areas for careful attention
• Methods
▫ Setting
▫ Measures
▫ Analysis
• Discussion
▫ Limitations (generalizability)

64. Summary
• QI projects are publishable as research
• Publishing QI can be challenging
• QI Publication requires careful planning
▫ IRB
▫ Generalizability