SQUIRE Blog
Welcome to the SQUIRE blogs, in which invited authors share their reflections on writing about their quality and safety work. These blogs are not a preview of that work and will contain little or no text or data from the authors' manuscripts. Rather, they provide an opportunity for authors to share their experiences with the process of writing, particularly the ways they use the SQUIRE guidelines, what's helpful about them, and what isn't.
The Heart of the Matter
Susan Mooney
My office is a little quirky. We have two distinct microsystems that inhabit the same space. A really small space, I might add. Two OB MDs and three Certified Nurse Midwives see obstetrics patients in the same building at the same time, yet they function as separate practices. Same manager and support staff but a different practice style that stems from philosophy. Our midwives believe in a true midwifery model. They believe that we, as a society, have medicalized pregnancy. Their primary mission as care providers is to provide education, support and comfort. They focus on wellness and relationships. They spend a lot of time with patients - an hour at the initial visit and then 1/2 hour each subsequent prenatal visit. They labor sit. They are firmly committed to quality patient care.
And yet, when I look at the data from the urine culture project, I am perplexed. The MD service has shown clear and steady improvement in both obtaining and documenting urine culture results. The CNM service - not so much. Every time I start to think we are making progress, we backslide. I have thought a lot about this. Sometimes, I think I understand what is going on in my office and other times I am baffled. All of the interventions have been the same for both services. Many of the support staff are the same. But, the processes that we introduce morph when the CNMs get ahold of them. And they morph in a way that negates the effectiveness. For example, the CNMs don't use the check-out form that the Docs love. They prefer to just tell the order to their support person who begins to drown in a barrage of verbal orders. We point this out to the CNMS. They nod and say they get it. They keep right on doing it. We talk about quality and ethics. They agree with me. They keep right on doing what they were doing before. It goes on and on.
I really want to understand what is going on but feel as though I am unable to do so. Perhaps we do not share a common definition of quality. Maybe the focus of the CNMs is on other things that they believe to be more important. Perhaps they see the use of standard checkout forms as less personal, less friendly and unnecessary. Direct, polite, verbal communication feels so much more human. And yet, a harried support person who is hearing 15 different verbal orders in 15 minutes is bound to make mistakes. She becomes flustered, stressed and is set up to fail. She makes mistakes. The system is unreliable. At the end of the day, I am frustrated with myself that I have been unable to solve this puzzle. Perhaps I have been too rational. Presenting data is clearly not the right tactic. I need to shift gears. Somehow, I need to make these issues resonate on a emotional level. I have no idea how to do that...
As I work through this project, I am beginning to think that the real story lies in understanding the difference between the MD and the Midwifery cultures. There is a lesson to be learned about designing interventions that respect those cultures and work with, rather than against, them. What works for the medical model that I know so well has faltered in the face of a different mental model of care. I need to understand this better if I have any hope of achieving meaningful change.
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Thinking about Generalizability
Susan Mooney
For the past few weeks I have been unable to do much in the way of writing. I have been thinking about my project - although it is a humble endeavor, it has made a difference in my clinic. I am confident that we now routinely and reliably collect 1st trimester urine cultures on more than 90% of the women who present for prenatal care. Part of me wants to shrug and say "about time" while another part of me knows that other places are just as deficient as we were. This is one of those tests that is so basic and so well accepted that everyone just assumes it is getting done. I bet no one really ever checks to see if their processes are working. I doubt that many facilities know their rate of 1st trimester urine culture screening.
Here's where I am - I know that I have identified and addressed a problem in my local environment. I suspect that other places have similar issues but I can't prove it. Further, I am betting that most people would just assume that they are getting this test done; therefore, my work will have no relevance to them. Which brings me around to the issue of generalizability. What have I learned that others don't know? What transcends my clinic? At its heart, this is a basic QI project that included all of the basics - an aim, process mapping, small tests of change as well as audit and feedback. In my local context, I have proven a couple of things: 1) These techniques works and 2) QI projects are hard work. I doubt that either of these things are news-flashes.
When I was in my Master's program I wrote a paper about developing a methodology to assess the quality of prenatal care at any given facility. I always thought that someday, I would write that paper again in a way that would allow for publication. The urine culture project was a spin off of that paper. It was a test to see if the methodology was workable in the real world. As I wrestle with writing up the urine culture project, i am wondering if I need to go back to the original paper. Does the urine culture project only make sense in the context of that larger body of work? Is it only in the two papers together that I find the material that is generalizable, that transcends APD and allows others to see a new way of thinking about high reliability prenatal care. If this is true, I am in trouble...I barely have enough time now to reflect and write. If I add another, more challenging, piece of work to my plate, I fear that nothing will get done. Except for the Flu vaccination project that I am starting. I hear that pregnant women are especially vulnerable to H1N1...
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The fits and starts of writing
Kathy Kirkland
Here I go again.
It's not that I haven't been writing; I just haven't been writing the hand hygiene piece. I allow myself to agree to other writing tasks and then I postpone the writing task that doesn't have an external deadline. But I have a renewed interest in getting this manuscript finished.
I spent the last week at "summer camp" for grownups committed to improving healthcare. I gained some new insights on my hand hygiene work from a criminologist. Yes, it seems there are parallels between my work and crime prevention! (How that never dawned on me before may be the stranger realization.) In any event, I have some good, new ideas about how to approach the next set of learning. But first, I absolutely must finish telling the current story. (It helped that the leader of our writing collaborative was also at summer camp. One look from him, and I squirm.)
So--this afternoon, between other things, and with a pile of things on my desk, I opened up my draft manuscript and started writing again, this time in the Results section. The way I see it (interpreting the Squire guidelines as they relate to my work) the task in this section is to answer two questions:
1) Did we do what we said we would do (in the methods)? (how well?)
2) Did it work? (ie, did hand hygiene improve, and did we have fewer infections?)
Obviously, the second question is easier to write the answer to--and is the stuff of "normal" scholarly manuscripts. The first question is the messy work of quality improvement, and of course the answer is no, not exactly--ie, we approximated what we set out to do, but there were deviations from the plan that are probably important to understand if you want to understand what about what we did worked.
I only got about a paragraph written, but I think the important part was figuring out that questions 1 and 2 need to be answered. It was helpful that back at the beginning of the project I laid out a 3 page document that outlined who was to be involved, in what role, and what the various workgroups were charged with. It helps to see that in writing so I can reflect on what did and didn't happen according to plan.
The SQUIRE guidelines continue to be helpful as signposts for me. It may become second nature to write this kind of paper...later.
Reading Sue's entries, I have to say that I feel pretty lucky to write in an environment where I can access the literature with a few keystrokes, and am surrounded by people who find my scholarly work familiar, at least on the surface.
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Separation
Susan Mooney
Although I enjoy my job, there are things that make it hard to work in a non-academic setting. The first is that "access to information isn't free" and the second is that "honest feedback is hard to find". I recently learned that my access to the Dartmouth Biomedical Libraries has been turned off. Apparently, my work with The Dartmouth Institute and the SQUIRE project does not qualify me for access. Without the library, my ability to access information has turned into a patchwork quilt. I can get abstracts off the web and some articles through the on-line library to which APD subscribes, but trying to do a comprehensive literature search is next door to impossible. At best, I find this mildly annoying. At worst, I think that limiting access to information must adversely affect the spread of good practice. Even if I succeed in publishing my work, who will see it? Is it worth expending a tremendous amount of time and energy to create a paper that collects dust on some obscure virtual bookcase? I get a sense that we need other ways to disseminate good ideas and good projects - ways that are more egalitarian that the traditional journal and library system.
Which brings me to the second point. During my training, it was easy to get feedback on my work. Sometimes, I got feedback even when I did not want it or did not have the time to deal with it. Now, I live in a feedback free zone. Perhaps my colleagues are just too polite, but I can't remember the last time anyone said anything other than "nice job" in reference to my work. I don't mind hearing those words but a little constructive criticism now and then would be helpful. Because of the absence of meaningful feedback at home, I am compelled to put my work "out there" for all to see and critique so that I can continue to learn and grow.
This attempt to publish from a non-academic setting is daunting. The system isn't set up to support or reward this type of work. From the lack of an IRB to the limited library access to colleagues who have different priorities, everything conspires to make this hard. This really is not about me and one little paper about Urine Cultures and pregnant women, it is about structure. There are two different healthcare worlds out there and we are only hearing about the experiences of one of them. I can't help but wonder about what is lost in the process.
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Ethics and The IRB
Susan Mooney
Memorial Day
The Friday before Memorial Day Weekend, I sat in on a meeting hosted by the VA Quality Scholars program. I was invited because the topic was ethics and the meeting organizers thought that I might be interested. I was. So I attended and now I wish that I had not. Although, that statement, is a bit misleading. I am glad I went, but in light of the conversation, I am not sure that I know what to do next. The basic premise that kicked off the meeting is that we need to assure that there is ethical oversight of Quality Improvement initiatives. At academic medical centers or VA medical centers that are affiliated with academic centers, this has meant that selected QI projects are vetted through IRBs and Research Committees. As a general rule, if a project leader has any thoughts of publishing his work, then he needs IRB approval. No thoughts of publication, No IRB. This simplistic reduction of a complex issue leaves me cold. Especially when I hear that QI projects have been delayed for months on end, awaiting IRB approval.
Can a Non-academic Publish?
One of the goals of the SQUIRE guidelines is to encourage non-academic QI people to reflect on and publish their work. In reality, this is an ambitious goal and the barriers are enormous. Non-academic people are not routinely rewarded for undertaking a writing project. They are rarely given time or support - they are too busy doing the work. Demanding IRB approval for QI studies feels like the proverbial "nail in the coffin". APD, where I work, has a small ethics committee that rarely meets. How would I access an IRB? If I only need IRB review so that I can publish, I will skip publication and just keep doing the work. But what if the work itself is unethical? How do we make sure that all QI work, published or not, is performed in an ethical way? The simplistic "if it is going to be published, it needs IRB approval" is wholly unsatisfactory. Everyone at the meeting understood this - no one had a good answer.
Are Delays Ethical?
On the one hand, an argument can be made that the QI work I am doing should have some sort of ethical review regardless of whether or not I intend to publish my work. But, on the other hand, I wonder about the academic facilities as well. Researchers at the meeting I went to told me that projects have been delayed for upwards of a year, awaiting IRB approval. Once we identify a gap in care and create a plan to close that gap, don't we have an ethical obligation to begin that work as soon as possible? How do we rationalize allowing sub-optimal care to persist for years at a time? And, oh, by the way, has anyone disclosed to the patients that the gap exists and that no one is working to fix it because the project plan is undergoing ethical review? How much harm is done in that year? Maybe less than what would have been done had the project moved forward, maybe more. It feels to me as though the ethical thing to do would be to make the calculation explicit.
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