Publishing your QI project

How do you know if your quality improvement project is a candidate for publication?.

Publishing the results of a successful quality improvement (QI) project in a peer-reviewed academic journal can boost a hospitalist's prestige and chance of promotion. But how do you know if your QI project is a candidate for publication?

The foremost determinant is whether your project has something new to offer or addresses a pressing problem, experts said. Journal editors also look for how well an author describes the process of implementing a successful intervention, so that a reader could replicate or adapt it for their institution.

Photo by Thinkstock
Photo by Thinkstock.

“A lot of QI work has to do with changing people's behavior, but the social structure of every hospital is different, so it's hard to generalize,” said Frank Davidoff, MACP, executive editor for the Institute for Healthcare Improvement and former editor of Annals of Internal Medicine. “The social aspects of a project need to be carefully observed and recorded.”

The Keystone ICU project, published in the Dec. 28, 2006 New England Journal of Medicine is an example of a QI project well-suited to publication, said Dr. Davidoff. Researchers on that project were able to demonstrate that adherence to five basic evidence-based steps, such as hand washing, by clinicians in over 100 Michigan ICUs led to a significant reduction in catheter-related bloodstream infections.

That study is notable not only because the intervention was successful but because the authors meticulously described their process, which enabled other hospitals to reproduce their results, he said. Lead author Peter Pronovost, MD, PhD, of Johns Hopkins University School of Medicine, recently led a similar study in Rhode Island that resulted in catheter-related bloodstream infections falling by 74% in 23 ICUs. The results were published in the December 2010 issue of Quality and Safety in Health Care.

“In the case of the Michigan study, it came down to what people needed to do at the bedside to prevent infections,” said Dr. Davidoff. “The research question was, ‘Can you get people to do these things on a consistent basis?’ It was an extremely elaborate social intervention.”

Make time to get it right

While every QI project may not be as elaborate or extensive as the Michigan study, it still takes significant time and attention to collect the data, document processes and write up the results as a polished manuscript that an editor will consider. That can be a challenge for a busy clinician.

It helps to have publishing in mind from the start of a project, said Vineet Arora, FACP, hospitalist and assistant dean for scholarship & discovery at the University of Chicago's Pritzker School of Medicine.

“A lot of times people have done something and they want to publish it but they find there's a flaw in the data or they missed a critical data collection period and that jeopardizes their ability to publish it,” she said. “If you want to be published, it's easier to plan ahead and say, ‘I am going to start a QI project with the goal of sharing it in a journal’ as opposed to ‘I'm going to take something off the shelf and turn it into a published paper.’”

Unfortunately, there's no magic solution to finding time to design, implement and report on an intervention while maintaining a busy clinical schedule. Plus, hospitalists may face pressure from their institutions to move onto the next project or to work on institutional priorities rather than pursuing publication.

“Usually, hospitals aren't paying you to write about QI, they're paying you to do it,” said Dr. Arora. “In order to close the loop and publish, you have to stick with the same project for a long time, but that sometimes doesn't fit with the mission of your organization. What if your organization has already asked you to move onto the next quality issue but you're still working on writing up the first project?”

In the face of those pressures, it's important to resist rushing through a project and potentially skipping over key steps, said Vikas Parekh, FACP, clinical assistant professor of internal medicine and associate director of the hospitalist program at the University of Michigan. “In the end you may have a great outcome, but if you can't show people which of those steps really mattered, that's a problem. If you can't show that something is better than [it would be] without the intervention, then it won't get published.”

A well-designed and executed study should show data before and after the intervention, include a control group and describe in detail how the intervention was implemented, said Dr. Parekh. “Also, explain what didn't work and why, and what you changed as a result.”

The SQUIRE (Standards for Quality Improvement Reporting Excellence) publishing guidelines provide a detailed description of how to report on QI projects. The official Web site outlines the guidelines, provides a checklist, and gives examples of each of the items on the checklist.

SQUIRE is the gold standard for what should be included in a formal QI study, said Dr. Davidoff, who helped develop the guidelines. Researchers do not have to cover every item on the checklist in order to get published, he noted, but it provides an overview of what categories to consider and what information to include.

Do your homework

There are many journals that publish QI studies but each has its own particular focus, so it's important to do some research before submitting your project.

Implementation Science, for example, a leading online quality and safety journal, focuses on large, rigorous, research-oriented studies, said the journal's editor-in-chief Brian Mittman, PhD. About half of the manuscripts submitted to IS pass peer review and are accepted for publication, he said.

To be considered, authors must draw a clear connection between their reported results and the QI activity being described, he said. For example, the journal often receives submissions focusing on improving diabetes care. Since diabetes care has been improving nationally across the board, the authors would have to show that their results are due to that specific QI intervention as opposed to external factors and influences, Dr. Mittman said.

Authors who do not take the time to research journals in advance may have to suffer through several rejections even though their study has something valuable to offer, he added. “Rejection of a manuscript should not always be interpreted as ‘this is not high quality work’; it just doesn't fit the target audience and scope of our journal.”

Other major quality and safety journals to consider include The Joint Commission Journal on Quality and Patient Safety, BMJ Quality and Safety, and PLoS Medicine. Top medical journals such as the New England Journal of Medicine, Annals of Internal Medicine and the Journal of the American Medical Association also publish some QI work.

In addition to looking carefully at the journals, it helps to enlist an experienced colleague as a mentor who will provide advice on the submission process and review drafts of your manuscript, said Dr. Arora. If you don't have experienced researchers at your hospital, look into joining a regional collaborative through your professional society.

A mentor may be able to offer advice on how to navigate your hospital's internal review board, for example, which may ask to approve the study. If approval is required, it's best to deal with it upfront rather than risk problems down the road, she said.

Remember to reach outside your “comfort zone” both for mentors and for colleagues interested in collaborating on your QI project or helping with writing, Dr. Arora added.

“QI requires a very complex set of talents—you need someone with an idea, a champion to motivate people to adopt change, and someone to evaluate it,” she said. “Sometimes one person can do all three, but more likely it will be two or three people. It's very important to investigate who can help you in those roles.”