Maximizing the Value of Single-Center Quality Improvement Reports

In this issue of the World Journal for Pediatric and Congenital Heart Surgery, Woodward and colleagues detail the experience of implementing and evaluating a combination of interventions to decrease the rate of sternal wound after pediatric cardiac surgery. The authors have attempted to intervene on a complication that is unique to our specialty, is associated with high clinical and financial costs, and for which there is scarce data to inform practices aimed at reducing its incidence. For these reasons, this article and others like it will no doubt spark interest in the journal’s readership. However, it would not be surprising for a reader to be left with a simple yet fundamental question, ‘‘What does this mean for my practice at my center?’’ Reporting of continuous quality improvement (QI) projects by journals geared to a clinical audience is now commonplace. Though many of these reports involve single-center interventions, thus raising questions about the generalizability of the findings (and hence the value of publishing such studies), they represent a vital early stage in the process of QI within a discipline. The UK Medical Research Council has likened single-center QI projects to phase 1 clinical trials in traditional clinical research. These modeling studies represent an opportunity to develop and test candidate interventions based on a clinical and theoretical framework of the problem requiring a QI solution. Public dissemination of single-center QI interventions, whether descriptive, analytic, or both, can generate new hypotheses and/or serve as the foundation for the development of larger scale projects. To maximize this priming effect, it is imperative that several key principles are considered by the authors and journal editors when writing and reviewing, respectively, QI research. These key principles are contained in a set of guidelines known as Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines. Building on the successes of other groups in creating reporting guidelines for methodologies like randomized-controlled trials (CONSORT) and meta-analyses (QUORUM, MOOSE), the authors of the SQUIRE guidelines generated a road map for authors and reviewers alike as a means to reduce variation in the way QI projects are reported. Acknowledging that there are inherent differences between QI projects and basic or clinical research trials with regard to study design, interventions, data collection, and analytic methods, the SQUIRE group has developed an explicit framework for sharing knowledge gained from local QI efforts. While an exhaustive review of all 19 SQUIRE checklist items is beyond the scope of this commentary, a closer examination of three important domains serves as an excellent starting point for pediatric cardiac surgeons, intensivists, and cardiologists interested in pursuing and publishing QI projects. These three key domains are (1) describing the planning of an intervention, (2) reporting outcomes, and (3) interpretation of the results. Perhaps the most important aspect of any QI report is a meticulous description of the actual intervention performed. This cannot be overemphasized: the intervention must be communicated explicitly enough to allow readers to reproduce the exact methodology in their own setting should they choose to do so. The reasoning behind choices made to include certain components instead of others is informative as the reader reflects on aspects of their own care system that could enhance or impede a similar intervention. A detailed timeline, delineation of the stepwise progression of the intervention, and description of team member roles and responsibilities are crucial factors to be considered. Attention to this detail increases the meaning and applicability to the reader, thus helping to answer the question posed earlier. Elucidating these contextual factors is even more critical in reporting QI research than for other study designs. Unlike randomized controlled trials, for instance, where context and setting are controlled for through randomization, readers of QI research need to understand how the intervention was influenced by the context in which it was carried out as it may be tightly coupled to the ultimate success or failure. Examples of contextual factors that impact implementation and success of a QI intervention include organizational culture and leadership, physical location, and characteristics of the patient population.