Greg Ogrinc

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Greg Ogrinc, MD, MS; Louise Davies, MD, MS; Daisy Goodman, DNP, MPH; Paul Batalden, MD; Frank Davidoff, MD; David Stevens, MD Perm J 2015 Fall; 19(4):65-70 [Full Citation] http://dx.do

Since the publication of Standards for Quality Improvement Reporting Excellence (SQUIRE 1.0) guidelines in 2008, the science of the field has advanced considerably. In this manuscript, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) semistructured interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) two face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes the reporting of 3 key components of systematic efforts to improve the quality, value, and safety of health care: the use of formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

In the past several years, the science of health care improvement has advanced considerably. In this article, we describe the development of SQUIRE 2.0 and its key components. We undertook the revision between 2012 and 2015 using (1) interviews and focus groups to evaluate SQUIRE 1.0 plus feedback from an international steering group, (2) face-to-face consensus meetings to develop interim drafts, and (3) pilot testing with authors and a public comment period. SQUIRE 2.0 emphasizes 3 key components of systematic efforts to improve the quality, value, and safety of health care: formal and informal theory in planning, implementing, and evaluating improvement work; the context in which the work is done; and the study of the intervention(s). SQUIRE 2.0 is intended for reporting the range of methods used to improve health care, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (www.squire-statement.org).

Purpose Learning about quality improvement (QI) in resident physician training is often relegated to elective or noncore clinical activities. The authors integrated teaching, learning, and doing QI into the routine clinical work of inpatient internal medicine teams at a Veterans Affairs (VA) hospital. This study describes the design factors that facilitated and inhibited the integration of a QI curriculum—including real QI work—into the routine work of inpatient internal medicine teams. Method A realist evaluation framework used three data sources: field notes from QI faculty; semistructured interviews with resident physicians; and a group interview with QI faculty and staff. From April 2011 to July 2012, resident physician teams at the White River Junction VA Medical Center used the Model for Improvement for their QI work and analyzed data using statistical process control charts. Results Three domains affected the delivery of the QI curriculum and engagement of residents in QI work: setting, learner, and teacher. The constant presence of the QI material on a public space in the team workroom was a facilitating mechanism in the setting. Explicit sign-out of QI work to the next resident team formalized the handoff in the learner domain. QI teachers who were respected clinical leaders with QI expertise provided role modeling and local system knowledge. Conclusions Integrating QI teaching into the routine clinical and educational systems of an inpatient service is challenging. Identifiable, concrete strategies in the setting, learner, and teacher domains helped integrate QI into the clinical and educational systems.

Educators have struggled with the best ways to teach the knowledge and skills of quality improvement to medical students. Dartmouth Medical School has a decade of experience incorporating this material into its curriculum. Working with faculty coaches, twenty-two second-year students have completed nine clinical improvement projects over the past four years. Students’ input has improved processes in our clinics for the collection of samples and scheduling of appointments. Instituting these changes is complex and requires a careful evaluation that describes and understands the educational context in order to establish successful and enduring curricular reform.

Health professions education researchers continually search for tools to measure, evaluate, and disseminate the findings from educational interventions. Clinical teaching, particularly teaching about the improvement of care and systems, is marked by complexity and is invariably influenced by the context into which the intervention is placed. The traditional research framework states that interventions should be adjudicated through a yes or no decision to determine effectiveness. In reality, educational interventions and the study of the interventions rarely succumb to such a simple yes or no question. The realist evaluation framework from Pawson and Tilley provides an explanatory model that links the context, mechanisms, and outcome patterns that are discovered during implementation of a project. This article describes the unique qualities of the realist evaluation, the basic components and steps in a realist evaluation, and an example that uses this technique to evaluate teaching about improvement of care in a clinical setting.