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Letter From the Editors

Using SQUIRE 2.0 to Guide Your Quality Improvement Work

Editor(s): McGrath, Jacqueline M. PhD, RN, FNAP, FAAN; Brandon, Debra PhD, RN, CCNS, FAAN

Author Information
doi: 10.1097/ANC.0000000000000362
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Dear NANN Colleagues,

A focus on quality improvement (QI) work in the healthcare environment is standard of care for high-performing settings that seek to ensure excellence in care. Providing care in the context of QI is about providing care with a goal of the best outcome at every step of the process. In an attempt to simplify the burden of QI, the process is being integrated into many routine caregiving tasks. Historically, QI occurred in the background of caregiving and was not discussed unless there was a “bad” event or there was a significant improvement or decline in an outcome of specific interest. Today, QI occurs on the front line of caregiving and is routinely discussed by all members of the healthcare team. Moreover, QI participation is recognized as an integral aspect of excellent nursing care that is particularly important in high-risk settings like the neonatal intensive care unit (NICU).

Why is QI so important that we all must participate? Quality improvement provides a basis for routine evaluation of daily healthcare activities that can positively or negatively affect infant outcomes. Reducing medical errors, increasing patient safety, and decreasing medical costs are all reasons to focus on QI work.1 Reimbursement is tied to the quality of the care provided; therefore, all healthcare systems must evaluate the QI work both “inside” and “outside” their environment. The questions that guide QI work are as follows: What are we doing? And, what can we do better, safer, and more efficaciously? To design QI work that provides important data on caregiving outcomes, the key features of an environment that contribute to outcomes must be considered, including the work culture of the environment.

Collecting data with sufficient rigor to generate ample evidence that is not only creditable but also reproducible in another clinical setting is a challenge for many healthcare professionals, including nurses. This means the work must be well planned and managed so that the findings can be shared within and external to the organization. Sharing outside of the organization is important not only for benchmarking against national standards but also for assisting others to improve their care. Today caregiving is fast paced and highly integrated across many disciplines and caregivers; therefore, to be sustainable, QI work must be easily integrated into the routine caregiving activities of the healthcare team, thereby leveraging resources.1

Why do we want to do it the best way we can? This question almost seems redundant, but it is important that we are continuously striving to provide the best healthcare possible. There will always be constraints, but using resources effectively to provide care that is of the highest quality should always be the goal. With the increased complexity in the healthcare setting, provision of excellent QI work has also become more complex and that complexity is demonstrated by the evolution of methods seen in implementation science. Yes, QI improvement work is now considered its own science. There is even a focus on QI at the national level with the establishment of the Agency for Healthcare Research and Quality.

Furthermore, publishing QI work in scholarly journals is important. Yet, what may be even more important is getting the information into routine care. This editorial outlines how best to move your scholarly QI work into publication. If we don't systematically document QI work, did it happen? If we don't share and demonstrate to others that you are meeting regional and national benchmarks, do consumers and other healthcare professionals trust that we are? These are important questions that force us to consider how best to share this work. Sometimes we read about QI projects in a journal and come away with more questions than answers. Have you ever read a QI project that you would like to replicate in your setting but the details of the process were not included in the report?2 To avoid this problem, the Standard for QUality Improvement Reporting Excellence (SQUIRE) guidelines were developed and recently refined.3

Increasing the visibility of your QI work. The best way to make your QI work more publishable is to first develop the QI work in your unit with a “real” plan. Focus on a few outcomes that have the potential to make a major difference in caregiving.1 For example, delivery room management could be a QI focus for neonatal intensive care teams because there is the potential for significant outcome changes. Once the focus of the QI project is chosen, clear measurable goals must be put into place with a timeline for meeting these objectives. To continue with our example, increasing quality in delivery room management, a multidisciplinary team will need to be assembled. Data will need to be collected; it is important that the data be rigorous without disrupting the care. So attention to the design of the project is important and should not be rushed. Consulting experts at this stage of the process can be important to collecting the right and most complete data. As researchers, the regret we often feel when we are into a project and realize we should have collected some data points that will be difficult to recover is not a good feeling but it happens, so taking time to consider the project outcomes and influencing factors before commencing data collection is important to getting the best results.

Using the SQUIRE guidelines to guide the development of your QI work is not just for making the work publishable; using SQUIIRE will help increase the overall quality of the QI work so that your original question about care is truly answered. The SQUIRE guidelines include a checklist for publication; however, it has been suggested that this checklist should be used to guide the development and implementation of the work as well. The SQUIRE checklist guides us to answer what might seem to be 4 simple questions.3

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

Furthermore, the checklist provides several key points for answering each of these questions. Using these key points in the development and publication of your project can actually improve the rigor of your QI work and help make it not only replicable but also more likely sustainable. Please consider using the SQUIRE guidelines to guide and publish your QI work. Advances in Neonatal Care requires use of the SQUIRE guidelines for publication in our journal, and if you submit your QI projects (which we hope you do) for publication, expect to see us refer you to the SQUIRE guidelines or to ask you to consider using SQUIRE to reformat your manuscript if you have not done so already. We believe that using the SQUIRE guidelines is a great framework for making QI work more meaningful to the care provided to high-risk infants and families in the NICU. We believe using the SQUIRE guidelines also makes the steps of publication of QI more obtainable by those doing the work—caregivers at the bedside.

Publishing your QI work is about telling the story of how your unit made or sustained a change in practice. Getting the message out about your QI work makes what you do every day have a bigger impact than just the single infant and family who just successfully left the NICU. These daily successes are important, but what is more important is that the strategies and practices you use to make a difference become routine (the way we do it) so that every infant and family successfully leaves the NICU. This means we need to learn from each other and continue to study and build the science of neonatal intensive care.

Thank you for your support,

Jacqueline M. McGrath, PhD, RN, FNAP, FAAN
Coeditor; Advances in Neonatal Care
[email protected]

Debra Brandon PhD, RN, CCNS, FAAN
Coeditor; Advances in Neonatal Care
[email protected]


1. Goodman D. Ten tips for incorporating scientific quality improvement into everyday work. BMJ Qual Saf. 2011;20(suppl 1):i69ei72. doi:10.1136/bmjqs.2010.046359.
2. Kennedy MS, Barnsteiner J. Reporting on quality improvement projects: where's the quality? Why are so many of these papers not publishable? Am J Nurs. 2016;116(9):7.
3. Ogrinc G, Davies L, Goodman D, et al. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence) revised publication guidelines from a detailed consensus process [published online ahead of print September 14, 2015]. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004411.
© 2016 by the National Association of Neonatal Nurses.