The SQUIRE reporting guideline for writing health services quality improvement research articles

The SQUIRE reporting guideline helps authors write health services quality improvement research articles that can be understood and used by a wide audience. This page summarises SQUIRE and how to use it.

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SQUIRE: Standards for QUality Improvement Reporting Excellence

Version: SQUIRE 2.0 2016 v1.1. This is the latest version ✅

How to use this reporting guideline

You can use reporting guidelines throughout your research process.

• When writing: consult the full guidance when writing manuscripts, protocols, and applications. The summary below provides a useful overview, and each item links to fuller guidance with explanations and examples.
• After writing: Complete a checklist and include it with your journal submission.
• To learn: Use SQUIRE and our training to develop as an academic and build writing skills.

However you use SQUIRE, please cite it.

Applicability criteria

Use SQUIRE for writing an article describing system level work to improve the quality, safety, and value of healthcare, and uses methods to establish that observed outcomes were due to the intervention(s). SQUIRE applies to the reporting of qualitative and quantitative evaluations of the nature and impact of interventions intended to improve healthcare, with the understanding that the guidelines may be adapted as needed for specific situations.

You can also use SQUIRE for:

• writing a protocol to test interventions to improve quality, safety and value of healthcare (use the items in the Introduction and Methods sections)
• you’re reviewing the reporting of a study of quality improvement research, but not for appraising its design or conduct

Do not use SQUIRE for:

• writing an article about quality improvement in medical education, use SQUIRE-EDU instead.
• writing an article about studies of implementation of healthcare improvement interventions, use STARI instead.

Summary of guidance

Although you should describe all items below, you can decide how to order and prioritize items most relevant to your study, findings, context, and readership whilst keeping your writing concise. You can read how SQUIRE was developed in the FAQs.

Item name	What to write
Title and Abstract
1. Title	Indicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centredness, timeliness, cost, efficiency and equity of healthcare).
2. Abstract	2a. Provide adequate information to aid in searching and indexing. 2b. Summarise 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, conclusions.
Introduction
3 & 4. Problem description & Available Knowledge	Nature and significance of the local problem. 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 aims	Purpose of the project and of this report.
Methods
7. Context	Contextual elements considered important at the outset of introducing the intervention(s).
8. Intervention(s)	Description of the intervention(s) in sufficient detail that others could reproduce it Specifics of the team involved in the work.
9. Study of the Intervention(s)	Approach chosen for assessing the impact of the intervention(s) Approach used to establish whether the observed outcomes were due to the intervention(s).
10. Measures	Measures chosen for studying processes and outcomes of the intervention(s), including rationale for choosing them, their operational definitions, and their validity and reliability Description of the approach to the ongoing assessment of contextual elements that contributed to t…
11. Analysis	Qualitative and quantitative methods used to draw inferences from the data 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
13 a & b. Evolution of the intervention and details of process measures	13a. Initial steps of the intervention(s) and their evolution over time (e.g., time-line diagram, flow chart, or table), including modifications made to the intervention during the project. 13b. Details of the process measures and outcome.
13 c, d & e Contextual elements and unexpected consequences	13c. Contextual elements that interacted with the interventions 13d. Observed associations between outcomes, interventions and relevant contextual factors 13e. Unintended consequences such as benefits, harms, unexpected results, problems or failures associated with the intervention(s)
13 e. Missing data	13e. Details about missing data.
Discussion
14. Summary	14a. Key findings, including relevance to the rationale and specific aims 14b. Particular strengths of the project
15. Interpretation	15a. Nature of the association between the intervention(s) and the outcomes 15b. Comparison of results with findings from other publications 15c. Impact of the project on people and systems 15d. Reasons for any differences between observed and anticipated outcomes, including the influence of context 15e. Costs and strategic trade-offs, including opportunity costs
16. Limitations	16a. Limits to the generalisability of the work. 16b. Factors that might have limited internal validity such as confounding, bias, or imprecision in the design, methods, measurement, or analysis. 16c. Efforts made to minimise and adjust for limitations.
17. Conclusion	17a. Usefulness of the work 17b. Sustainability 17c. Potential for spread to other contexts 17d. Implications for practice and for further study in the field 17e. Suggested next steps
Other information
18. Funding	Sources of funding that supported this work. Role, if any, of the funding organisation in the design, implementation, interpretation and reporting.

Including the appropriate EQUATOR checklist as part of your submission goes a long way to help establish trust between authors, editors, and reviewers. That’s why our editorial team ensures that applicable reporting checklists are completed during the peer review process, with a completed checklist at submission greatly helping editors and peer reviewers to assess the work.

Adrian Aldcroft

Editor in Chief, BMJ Open

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Assumptions

Reasons for choosing the activities and tools used to bring about changes in healthcare services at the system level. Source

Context

Physical and sociocultural makeup of the local environment (for example, external environmental factors, organizational dynamics, collaboration, resources, leadership, and the like), and the interpretation of these factors (“sense-making”) by the healthcare delivery professionals, patients, and caregivers that can affect the effectiveness and generalizability of intervention(s). Source

Ethical aspects

The value of system-level initiatives relative to their potential for harm, burden, and cost to the stakeholders. Potential harms particularly associated with efforts to improve the quality, safety, and value of healthcare services include opportunity costs, invasion of privacy, and staff distress resulting from disclosure of poor performance.

Generalizability

The likelihood that the intervention(s) in a particular report would produce similar results in other settings, situations, or environments (also referred to as external validity). Source

Healthcare improvement

Any systematic effort intended to raise the quality, safety, and value of healthcare services, usually done at the system level. We encourage the use of this phrase rather than “quality improvement,” which often refers to more narrowly defined approaches. Source

Inferences

The meaning of findings or data, as interpreted by the stakeholders in healthcare services - improvers, healthcare delivery professionals, and/or patients and families. Source

Initiative

A broad term that can refer to organization-wide programs, narrowly focused projects, or the details of specific interventions (for example, planning, execution, and assessment). Source

Internal validity

Demonstrable, credible evidence for efficacy (meaningful impact or change) resulting from introduction of a specific intervention into a particular healthcare system. Source

Interventions

The specific activities and tools introduced into a healthcare system with the aim of changing its performance for the better. Complete description of an intervention includes its inputs, internal activities, and outputs (in the form of a logic model, for example), and the mechanism(s) by which these components are expected to produce changes in a system’s performance. Source #TODO check matches

Opportunity costs

Loss of the ability to perform other tasks or meet other responsibilities resulting from the diversion of resources needed to introduce, test, or sustain a particular improvement initiative. Source

Problem

Meaningful disruption, failure, inadequacy, distress, confusion or other dysfunction in a healthcare service delivery system that adversely affects patients, staff, or the system as a whole, or that prevents care from reaching its full potential. Source

process

The routines and other activities through which healthcare services are delivered. Source

Rationale

Explanation of why particular intervention(s) were chosen and why it was expected to work, be sustainable, and be replicable elsewhere. Source

Systems

The interrelated structures, people, processes, and activities that together create healthcare services for and with individual patients and populations. For example, systems exist from the personal self-care system of a patient, to the individual provider-patient dyad system, to the microsystem, to the macrosystem, and all the way to the market/social/insurance system. These levels are nested within each other. Source

Theory

Any “reason-giving” account that asserts causal relationships between variables (causal theory) or that makes sense of an otherwise obscure process or situation (explanatory theory). Theories come in many forms, and serve different purposes in the phases of improvement work. It is important to be explicit and well-founded about any informal and formal theory (or theories) that are used. Source