Original Article Open Access

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised Publication Guidelines From a Detailed Consensus Process

Greg Ogrinc, MD, MS; Louise Davies, MD, MS; Daisy Goodman, DNP, MPH; Paul Batalden, MD; Frank Davidoff, MD; David Stevens, MD

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Abstract

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) semi-structured 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 three key components of systematic efforts to improve the quality, value, and safety of healthcare: 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 healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

J Contin Educ Nurs. 2015;46(11):501–507.

In 2005, draft publication guidelines for quality improvement reporting debuted in Quality and Safety in Health Care.1 At that time, publications of scholarly work about healthcare improvement were often confusing and of limited value. Leaders in the field were working to consolidate the evidence for a science of improvement2,3 and without guidance on how to write their findings, authors struggled to report their improvement work in a reliable and consistent way.4,5 These factors influenced the initial publication in 2008 of the Standards for QUality Improvement Reporting Excellence (SQUIRE),6 which we will refer to as SQUIRE 1.0. The guidelines were developed in an effort to reduce uncertainty about the information deemed to be important in scholarly reports of healthcare improvement and to increase the completeness, precision, and transparency of those reports.

In the intervening years, the reach of systematic efforts to improve the quality, safety, and value of healthcare has grown. Health professionals’ education worldwide now includes improvement as a standard competency.7–11 The science of the field also continues to advance through guidance on applying formal and informal theory in the development and interpretation of improvement programs12; stronger ways to identify, assess, and describe context13–16; recommendations for clearer, more complete descriptions of interventions17; and development of initial guidance on how to study an intervention.18

In this setting, we have undertaken a revision of SQUIRE 1.0. When we began, it rapidly became apparent that a wide variety of approaches had developed for improving healthcare, ranging from formative to experimental to evaluative. Rather than limit the revised guidelines to only a few of these, we fashioned them to be applicable across the many methods that are used. We aimed to reflect the dynamic nature of the field and support its further development. This article describes the development and content of SQUIRE 2.0 (Table 1).

Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication GuidelinesRevised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Table 1:

Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

SQUIRE 2.0 Developmental Path

We developed SQUIRE 2.0 between 2012 and 2015 in three overlapping phases: (1) evaluation of the initial SQUIRE guidelines, (2) early revisions, and (3) pilot testing with late revisions.

We began the evaluation of SQUIRE 1.0 by collecting data to assess its clarity and usability.19 Semi-structured interviews and focus groups with 29 end users of SQUIRE 1.0 revealed that many found SQUIRE 1.0 helpful in planning and doing improvement work, but less so in the writing process. This issue was especially apparent in efforts to write about the cyclic, iterative process that often occurs with improvement interventions. SQUIRE 1.0 was seen by many as unnecessarily complex with too much redundancy and lacking a clear distinction between “doing improvement” and “studying the improvement.” A recent independent study and editorial also documented and addressed some of these challenges.20,21

In the second phase, we convened an international advisory group of 18 experts that included editors, authors, researchers, and improvement professionals. This group met through three conference calls, reviewed SQUIRE 1.0 and the results of the end-user evaluation, and provided detailed feedback on successive revisions. This advisory group and additional participants attended two consensus conferences in 2013 and 2014 where they engaged in intensive analysis and made recommendations that further guided the revision process.

In the third phase, 44 authors used an interim draft version of the updated SQUIRE guidelines to write sections of a manuscript. Each author then provided comments on the utility and understandability of the draft guidelines, and in their submitted section, identified the portions of their writing sample that fulfilled the items of that section.22 We also obtained detailed feedback about this draft version through semistructured interviews with 11 biomedical journal editors. The data from this phase revealed areas needing further clarification and which specific items were prone to misinterpretation. Finally, a penultimate draft was emailed to over 450 individuals around the world, including the advisory group, consensus meeting participants, authors, reviewers, editors, faculty in fellowship programs, and trainees. This version was also posted on the SQUIRE website with an invitation for public feedback. We used the information from this process to write SQUIRE 2.0 (Table 1).

SQUIRE 2.0

Many publication guidelines, including CONSORT (randomized trials), STROBE (observational studies), and PRISMA (systematic reviews) focus on a particular study methodology ( http://www.equator-network.org). In contrast, SQUIRE 2.0 is designed to apply across the many approaches used for systematically improving the quality, safety, and value of healthcare. Methods range from iterative changes using PDSA cycles in single settings to retrospective analyses of large-scale programs to multisite randomized trials. We encourage authors to apply other publication guidelines—particularly those that focus on specific study methods—along with SQUIRE, as appropriate. Authors should carefully consider the relevance of each SQUIRE item but recognize that it is sometimes not necessary, nor even possible, to include each item in a particular manuscript.

SQUIRE 2.0 retains the IMRaD (Introduction, Methods, Results, and Discussion) structure.23 Although used primarily for reporting research within a spectrum of study designs, this structure expresses the underlying logic of most systematic investigations and is familiar to authors, editors, reviewers, and readers. We continue to use A. Bradford Hill’s four fundamental questions for writing: Why did you start? What did you do? What did you find? What does it mean?24 In our evaluation of SQUIRE 1.0, novice authors found these questions to be straightforward, clear, and useful.

SQUIRE 2.0 contains 18 items but omits the multiple subitems that were a source of confusion for SQUIRE 1.0 users.19 A range of approaches exists for improving healthcare, and SQUIRE may be adapted for reporting any of these. As stated above, authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE item in a particular manuscript. In addition, authors need not use items in the order in which they appear. Major changes between SQUIRE 1.0 and 2.0 are concentrated in four areas: (1) terminology, (2) theory, (3) context, and (4) studying the intervention(s).

Terminology

The elaborate detail in SQUIRE 1.0 was seen by users as a both a blessing and a curse19: helpful in designing and executing quality improvement work but less useful in the writing process. The level of detail sometimes led to confusion about what to include or not include in a manuscript. Consequently, we made the items in SQUIRE 2.0 shorter and more direct.

A major challenge in the reporting of systematic efforts to improve healthcare is the multiplicity of terms used to describe the work, which is challenging for novices and experts alike. Improvement work draws on the epistemology of a variety of fields, and depending on one’s field of study, the same words can carry different connotations, a particularly undesirable state of affairs. Terms such as “quality improvement,” “implementation science,” and “improvement science” refer to approaches that have many similarities but can also connote important (and often-debated) differences. Other terms such as “healthcare delivery science,” “patient safety,” and even simply “improvement” are also subject to surprising variation in interpretation. To address this problem in semantics, we created a glossary of terms used in SQUIRE 2.0 (Table 2). The glossary provides the intended meaning of certain key terms as we have used them in SQUIRE 2.0 (Table 1). These definitions may be helpful in other endeavors but are not necessarily intended to be adopted for use in other contexts. Overall, we sought terms and definitions that would be useful to the largest possible audience. For example, we chose “intervention(s)” to refer to the changes that are made. We decided not to use the word “improvement” in the individual items (although it remains in the SQUIRE acronym) to encourage authors to report efforts that did not lead to changes for the better. Reporting well-done, negative studies is vital for the learning in this discipline.

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)a

Table 2:

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)

Theory

SQUIRE 2.0 includes a new item titled “rationale.” Biomedical and clinical research is driven by iterative cycles of theory building and hypothesis testing. Healthcare improvement work has not consistently based the planning, design, and execution of its programs solidly in theory, to the detriment of the work. For this reason, SQUIRE 2.0 explicitly includes an item devoted to theory, although we chose to use the broader and less technical label “rationale,” to encourage authors to be explicit in reporting formal and informal theories, models, concepts, or even hunches as to why they expected a particular intervention to work in a particular context. A plain language interpretation of “rationale” might be, “Why did you think this would work?” A recent narrative review of the nature of theory and its use in improvement describes the many types and applications of theory, and considers pitfalls in using and not using theory.12

The addition of the “Rationale” item is intended to encourage clarity around assumptions about the nature of the intervention, the context, and the expected outcomes. The presence of a well thought out rationale will align with appropriate measures and with the study of the intervention; it may also be the starting point for the next round of work. The “Summary” item in the Discussion section encourages authors to revisit the original rationale in the light of its findings and in the larger context of similar projects.

Context

SQUIRE 2.0 accepts “context” as the key features of the environment in which the work is immersed and which are interpreted as meaningful to the success, failure, and unexpected consequences of the intervention(s), as well as the relationship of these to the stakeholders (e.g., improvement team, clinicians, patients, families, etc.).13–16 Systematic efforts to improve healthcare should contain clear descriptions and acknowledgment of context, rather than efforts to control it or explain it away. SQUIRE 1.0 included context with items in all sections of the manuscript, but context did not rise to the level of a distinct item itself. SQUIRE 2.0 recognizes context as a fundamental item in the methods section, but its relevance is not limited to this section. In addition to affecting the development of the rationale and subsequent design of the intervention(s), context plays a key role in the iterations of intervention(s) and the outcomes. While it is often not simple to capture or describe context, understanding its impact on the design, implementation, measurement, and results make it a vital contributor in identifying and reporting the factors and mechanisms responsible for the success or failure of the intervention(s).

Studying the Intervention(s)

The study of the intervention is, perhaps, the most challenging item in SQUIRE. In the evaluation of SQUIRE 1.019 and in the pilot testing,22 many were perplexed by this item and its subelements. This item was intended to encourage a more formal assessment of the intervention and its associated outcomes. In SQUIRE 2.0, this section is called, “Study of the Intervention(s)” (Table 1).

“Doing” an improvement project is fundamentally different from “studying” it. The primary purpose of “doing” improvement is to produce better local processes and outcomes, rather than contribute to new generalizable knowledge. In contrast, the reason for “studying” the intervention is mainly to contribute to the body of knowledge about the efficacy and generalizability of efforts for improving healthcare. Both “doing” and “studying” are required for a deep understanding of the nature and impact of the intervention(s), as well as the possible underlying mechanisms. “Study of the Intervention(s)” focuses mainly on whether and why an intervention “works.” It should align with the rationale and may include, but is not limited to, preplanned formal testing of the proposed theory that the intervention(s) actually produced the observed changes, as well as the impact of the intervention(s) on the context in which the work was done.

SQUIRE 2.0 asks authors to be as transparent, complete, and as accurate as possible about reporting “doing” and “studying” improvement work, as both aspects of the work are key to scholarly reporting. The “Summary” and “Interpretation” items in the Discussion encourage authors to explain potential mechanisms by which the intervention(s) resulted (or failed to result) in change, thereby developing explanatory theories that can be subsequently tested.

Conclusions

The development of SQUIRE 2.0 consisted of a detailed analysis of SQUIRE 1.0, input from experts in the field, and thorough pilot testing. Many methods and philosophical approaches to improve the quality, safety, and value of healthcare are available. The systematic efforts to improve healthcare are often complex and multi-dimensional, and their effectiveness is inherently context dependent. SQUIRE 2.0 provides common ground on which the discoveries contributed by the various approaches can advance the field by sharing them in the published literature.

At the same time, we recognize that simply publishing SQUIRE 2.0 will not effect this change; additional efforts and resources are required. For example, we have created an explanation and elaboration (E&E) document (Goodman D, Ogrinc G, Davies L; personal communication, 2015) to accompany this article. For each item in SQUIRE 2.0, the E&E provides one or more examples from the published literature and a commentary on how the example(s) meets or does not meet the item’s standards; this information brings the content of each item to life. The SQUIRE website ( http://www.squire-statement.org) contains a number of resources, in addition to the guidelines themselves, including interactive E&E pages and video commentaries. The website supports an emerging online community for the continuous use, conversation about, and evaluation of the guidelines.

Writing about improvement can be challenging. Sharing successes, failures, and developments through scholarly literature is an essential component of the complex work required in order to improve healthcare services for patients, professionals, and the public.

References

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Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Text Section and Item NameSection or Item Description
Notes to authorsThe SQUIRE guidelines provide a framework for reporting new knowledge about how to improve healthcare.
The SQUIRE guidelines are intended for reports that describe system level work to improve the quality, safety, and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s).
A range of approaches exists for improving healthcare. SQUIRE may be adapted for reporting any of these.
Authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE element in a particular manuscript.
The SQUIRE Glossary contains definitions of many of the key words in SQUIRE.
The Explanation and Elaboration document provides specific examples of well-written SQUIRE items and an in-depth explanation of each item.
Please cite SQUIRE when it is used to write a manuscript.
Title and abstract
  1. TitleIndicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centeredness, timeliness, cost, efficiency, and equity of healthcare).
  2. Abstract

Provide adequate information to aid in searching and indexing

Summarize all key information from various sections of the text using the abstract format of the intended publication or a structured summary, such as background, local problem, methods, interventions, results, conclusions

IntroductionWhy did you start?
  3. Problem descriptionNature and significance of the local problem
  4. Available knowledgeSummary of what is currently known about the problem, including relevant previous studies
  5. RationaleInformal or formal frameworks, models, concepts, and/or theories used to explain the problem, any reasons or assumptions that were used to develop the intervention(s), and reasons why the intervention(s) was expected to work
  6. Specific aimsPurpose of the project and of this report
MethodsWhat did you do?
  7. ContextContextual elements considered important at the outset of introducing the intervention(s)
  8. Intervention(s)

Description of the intervention(s) in sufficient detail that others could reproduce it

Specifics of the team involved in the work

  9. Study of the Intervention(s)

Approach chosen for assessing the impact of the intervention(s)

Approach used to establish whether the observed outcomes were due to the intervention(s)

10. Measures

Measures chosen for studying processes and outcomes of the intervention(s), including rationale for choosing them, their operational definitions, and their validity and reliability

Description of the approach to the ongoing assessment of contextual elements that contributed to the success, failure, efficiency, and cost

Methods employed for assessing completeness and accuracy of data

  11. Analysis

Qualitative and quantitative methods used to draw inferences from the data

Methods for understanding variation within the data, including the effects of time as a variable

  12. Ethical considerationsEthical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest
ResultsWhat did you find?
  13. Results

Initial steps of the intervention(s) and their evolution over time (e.g., time-line diagram, flow chart, or table), including modifications made to the intervention during the project

Details of the process measures and outcome

Contextual elements that interacted with the intervention(s)

Observed associations between outcomes, interventions, and relevant contextual elements

Unintended consequences, such as unexpected benefits, problems, failures, or costs associated with the intervention(s)

Details about missing data

DiscussionWhat does it mean?
  14. Summary

Key findings, including relevance to the rationale and specific aims

Particular strengths of the project

  15. Interpretation

Nature of the association between the intervention(s) and the outcomes

Comparison of results with findings from other publications

Impact of the project on people and systems

Reasons for any differences between observed and anticipated outcomes, including the influence of context

Costs and strategic trade-offs, including opportunity costs

  16. Limitations

Limits to the generalizability of the work

Factors that might have limited internal validity, such as confounding, bias, or imprecision, in the design, methods, measurement, or analysis

Efforts made to minimize and adjust for limitations

  17. Conclusions

Usefulness of the work

Sustainability

Potential for spread to other contexts

Implications for practice and for further study in the field

Suggested next steps

Other information
  18. FundingSources of funding that supported this work. Role, if any, of the funding organization in the design, implementation, interpretation, and reporting

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)a

Assumptions
Reasons for choosing the activities and tools used to bring about changes in healthcare services at the system level.
Context
Physical and sociocultural makeup of the local environment (e.g., external environmental factors, organizational dynamics, collaboration, resources, leadership, and the like), and the interpretation of these factors (“sense-making”) by the healthcare delivery professionals, patients, and caregivers that can affect the effectiveness and generalizability of intervention(s).
Ethical aspects
The value of system-level initiatives relative to their potential for harm, burden, and cost to the stakeholders. Potential harms particularly associated with efforts to improve the quality, safety, and value of healthcare services include opportunity costs, invasion of privacy, and staff distress resulting from disclosure of poor performance.25
Generalizability
The likelihood that the intervention(s) in a particular report would produce similar results in other settings, situations, or environments (also referred to as external validity).
Healthcare improvement
Any systematic effort intended to raise the quality, safety, and value of healthcare services, usually done at the system level. We encourage the use of this phrase rather than “quality improvement,” which often refers to more narrowly defined approaches.
Inferences
The meaning of findings or data, as interpreted by the stakeholders in healthcare services—improvers, healthcare delivery professionals, and/or patients and families.
Initiative
A broad term that can refer to organization-wide programs, narrowly focused projects, or the details of specific interventions (e.g., planning, execution, assessment)
Internal validity
Demonstrable, credible evidence for efficacy (meaningful impact or change) resulting from introduction of a specific intervention into a particular healthcare system.
Intervention(s)
The specific activities and tools introduced into a healthcare system with the aim of changing its performance for the better. Complete description of an intervention includes its inputs, internal activities, and outputs (e.g., in the form of a logic model), and the mechanism(s) by which these components are expected to produce changes in a system’s performance.17
Opportunity costs
Loss of the ability to perform other tasks or meet other responsibilities resulting from the diversion of resources needed to introduce, test, or sustain a particular improvement initiative.
Problem
Meaningful disruption, failure, inadequacy, distress, confusion or other dysfunction in a healthcare service delivery system that adversely affects patients, staff, or the system as a whole, or that prevents care from reaching its full potential.
Process
The routines and other activities through which healthcare services are delivered
Rationale
Explanation of why particular intervention(s) were chosen and why it was expected to work, be sustainable, and be replicable elsewhere.
Systems
The interrelated structures, people, processes, and activities that together create healthcare services for and with individual patients and populations. For example, systems exist from the personal self-care system of a patient to the individual provider–patient dyad system, to the microsystem, to the macrosystem, and all the way to the market/social/insurance system. These levels are nested within each other.
Theory or theories
Any “reason-giving” account that asserts causal relationships between variables (causal theory) or that makes sense of an otherwise obscure process or situation (explanatory theory). Theories come in many forms, and serve different purposes in the phases of improvement work. It is important to be explicit and well-founded about any informal and formal theory (or theories) that are used.
Authors

Dr. Ogrinc is Senior Associate Dean for Medical Education, Geisel School of Medicine at Dartmouth, Associate Chief of Staff for Education, White River Junction VA, White River Junction, Vermont, and Associate Professor of Community and Family Medicine, Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Davies is Senior Scholar, Quality Scholars Program, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Associate Professor of Surgery, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover New Hampshire; Dr. Goodman is Fellow, VA Quality Scholars Fellowship Program, and Instructor, Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Batalden is Active Emeritus Professor, Pediatrics and Community and Family Medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Dr. Davidoff is Editor Emeritus, Annals of Internal Medicine, and Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and Dr. Stevens is Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, Editor Emeritus, BMJ Quality and Safety, London, United Kingdom, and Senior Fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Name and affiliation of members of the SQUIRE 2.0 advisory group: Davina Allen, Cardiff University, UK; Ross Baker, University of Toronto, Canada; Helen Crisp, Health Foundation, UK; Mary Dixon-Woods, University of Leicester, UK; Don Goldmann, Institute for Healthcare Improvement, USA; Steve Goodman, Stanford University, USA; Leora Horwitz, New York University, USA; Pam Ironside, Indiana University, USA; Peter Margolis, University of Cincinnati, USA; Paul Miles, American Board of Pediatrics, USA; Shirley Moore, Case Western Reserve University, USA; Peter Pronovost, Johns Hopkins University, USA; Lisa Rubenstein, University of California Los Angeles, USA; Gwen Sherwood, University of North Carolina, USA; Kaveh Shojania, University of Toronto, Canada; Richard Thomson, Newcastle University, UK; Charles Vincent, Imperial College London, UK; and Hub Wollersheim, Radboud University Medical Center, the Netherlands.

© 2015 BMJ Quality & Safety; licensee SLACK Incorporated. Originally published in BMJ Quality and Safety, Published Online First: 14 September 2015. doi:10.1136/bmjqs-2015-004411. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

This paper is being co-published in: American Journal of Critical Care, American Journal of Medical Quality, Canadian Journal of Diabetes, The Journal of Continuing Education in Nursing, Journal of American College of Surgeons, Journal of Surgical Research, Joint Commission Journal on Quality and Patient Safety, Journal of Nursing Care Quality, The Permanente Journal, GIMBE Evidence for Health (Italy), and MedWave (Chile).

This material is based on work supported by the Health Foundation (grant number 7099) and the Robert Wood Johnson Foundation (grant number 70024), and included the use of facilities and material at the White River Junction VA in White River Junction, Vermont.

Received: May 19, 2015
Accepted: July 17, 2015

10.3928/00220124-20151020-02

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) semi-structured 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 three key components of systematic efforts to improve the quality, value, and safety of healthcare: 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 healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

J Contin Educ Nurs. 2015;46(11):501–507.

Dr. Ogrinc is Senior Associate Dean for Medical Education, Geisel School of Medicine at Dartmouth, Associate Chief of Staff for Education, White River Junction VA, White River Junction, Vermont, and Associate Professor of Community and Family Medicine, Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Davies is Senior Scholar, Quality Scholars Program, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Associate Professor of Surgery, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover New Hampshire; Dr. Goodman is Fellow, VA Quality Scholars Fellowship Program, and Instructor, Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Batalden is Active Emeritus Professor, Pediatrics and Community and Family Medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Dr. Davidoff is Editor Emeritus, Annals of Internal Medicine, and Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and Dr. Stevens is Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, Editor Emeritus, BMJ Quality and Safety, London, United Kingdom, and Senior Fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Name and affiliation of members of the SQUIRE 2.0 advisory group: Davina Allen, Cardiff University, UK; Ross Baker, University of Toronto, Canada; Helen Crisp, Health Foundation, UK; Mary Dixon-Woods, University of Leicester, UK; Don Goldmann, Institute for Healthcare Improvement, USA; Steve Goodman, Stanford University, USA; Leora Horwitz, New York University, USA; Pam Ironside, Indiana University, USA; Peter Margolis, University of Cincinnati, USA; Paul Miles, American Board of Pediatrics, USA; Shirley Moore, Case Western Reserve University, USA; Peter Pronovost, Johns Hopkins University, USA; Lisa Rubenstein, University of California Los Angeles, USA; Gwen Sherwood, University of North Carolina, USA; Kaveh Shojania, University of Toronto, Canada; Richard Thomson, Newcastle University, UK; Charles Vincent, Imperial College London, UK; and Hub Wollersheim, Radboud University Medical Center, the Netherlands.

© 2015 BMJ Quality & Safety; licensee SLACK Incorporated. Originally published in BMJ Quality and Safety, Published Online First: 14 September 2015. doi:10.1136/bmjqs-2015-004411. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

This paper is being co-published in: American Journal of Critical Care, American Journal of Medical Quality, Canadian Journal of Diabetes, The Journal of Continuing Education in Nursing, Journal of American College of Surgeons, Journal of Surgical Research, Joint Commission Journal on Quality and Patient Safety, Journal of Nursing Care Quality, The Permanente Journal, GIMBE Evidence for Health (Italy), and MedWave (Chile).

This material is based on work supported by the Health Foundation (grant number 7099) and the Robert Wood Johnson Foundation (grant number 70024), and included the use of facilities and material at the White River Junction VA in White River Junction, Vermont.

Received: May 19, 2015
Accepted: July 17, 2015

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) semi-structured 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 three key components of systematic efforts to improve the quality, value, and safety of healthcare: 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 healthcare, recognizing that they can be complex and multidimensional. It provides common ground to share these discoveries in the scholarly literature (http://www.squire-statement.org).

J Contin Educ Nurs. 2015;46(11):501–507.

Dr. Ogrinc is Senior Associate Dean for Medical Education, Geisel School of Medicine at Dartmouth, Associate Chief of Staff for Education, White River Junction VA, White River Junction, Vermont, and Associate Professor of Community and Family Medicine, Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Davies is Senior Scholar, Quality Scholars Program, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Associate Professor of Surgery, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover New Hampshire; Dr. Goodman is Fellow, VA Quality Scholars Fellowship Program, and Instructor, Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Batalden is Active Emeritus Professor, Pediatrics and Community and Family Medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Dr. Davidoff is Editor Emeritus, Annals of Internal Medicine, and Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and Dr. Stevens is Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, Editor Emeritus, BMJ Quality and Safety, London, United Kingdom, and Senior Fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Name and affiliation of members of the SQUIRE 2.0 advisory group: Davina Allen, Cardiff University, UK; Ross Baker, University of Toronto, Canada; Helen Crisp, Health Foundation, UK; Mary Dixon-Woods, University of Leicester, UK; Don Goldmann, Institute for Healthcare Improvement, USA; Steve Goodman, Stanford University, USA; Leora Horwitz, New York University, USA; Pam Ironside, Indiana University, USA; Peter Margolis, University of Cincinnati, USA; Paul Miles, American Board of Pediatrics, USA; Shirley Moore, Case Western Reserve University, USA; Peter Pronovost, Johns Hopkins University, USA; Lisa Rubenstein, University of California Los Angeles, USA; Gwen Sherwood, University of North Carolina, USA; Kaveh Shojania, University of Toronto, Canada; Richard Thomson, Newcastle University, UK; Charles Vincent, Imperial College London, UK; and Hub Wollersheim, Radboud University Medical Center, the Netherlands.

© 2015 BMJ Quality & Safety; licensee SLACK Incorporated. Originally published in BMJ Quality and Safety, Published Online First: 14 September 2015. doi:10.1136/bmjqs-2015-004411. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

This paper is being co-published in: American Journal of Critical Care, American Journal of Medical Quality, Canadian Journal of Diabetes, The Journal of Continuing Education in Nursing, Journal of American College of Surgeons, Journal of Surgical Research, Joint Commission Journal on Quality and Patient Safety, Journal of Nursing Care Quality, The Permanente Journal, GIMBE Evidence for Health (Italy), and MedWave (Chile).

This material is based on work supported by the Health Foundation (grant number 7099) and the Robert Wood Johnson Foundation (grant number 70024), and included the use of facilities and material at the White River Junction VA in White River Junction, Vermont.

Received: May 19, 2015
Accepted: July 17, 2015

In 2005, draft publication guidelines for quality improvement reporting debuted in Quality and Safety in Health Care.1 At that time, publications of scholarly work about healthcare improvement were often confusing and of limited value. Leaders in the field were working to consolidate the evidence for a science of improvement2,3 and without guidance on how to write their findings, authors struggled to report their improvement work in a reliable and consistent way.4,5 These factors influenced the initial publication in 2008 of the Standards for QUality Improvement Reporting Excellence (SQUIRE),6 which we will refer to as SQUIRE 1.0. The guidelines were developed in an effort to reduce uncertainty about the information deemed to be important in scholarly reports of healthcare improvement and to increase the completeness, precision, and transparency of those reports.

In the intervening years, the reach of systematic efforts to improve the quality, safety, and value of healthcare has grown. Health professionals’ education worldwide now includes improvement as a standard competency.7–11 The science of the field also continues to advance through guidance on applying formal and informal theory in the development and interpretation of improvement programs12; stronger ways to identify, assess, and describe context13–16; recommendations for clearer, more complete descriptions of interventions17; and development of initial guidance on how to study an intervention.18

In this setting, we have undertaken a revision of SQUIRE 1.0. When we began, it rapidly became apparent that a wide variety of approaches had developed for improving healthcare, ranging from formative to experimental to evaluative. Rather than limit the revised guidelines to only a few of these, we fashioned them to be applicable across the many methods that are used. We aimed to reflect the dynamic nature of the field and support its further development. This article describes the development and content of SQUIRE 2.0 (Table 1).

Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication GuidelinesRevised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Table 1:

Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

SQUIRE 2.0 Developmental Path

We developed SQUIRE 2.0 between 2012 and 2015 in three overlapping phases: (1) evaluation of the initial SQUIRE guidelines, (2) early revisions, and (3) pilot testing with late revisions.

We began the evaluation of SQUIRE 1.0 by collecting data to assess its clarity and usability.19 Semi-structured interviews and focus groups with 29 end users of SQUIRE 1.0 revealed that many found SQUIRE 1.0 helpful in planning and doing improvement work, but less so in the writing process. This issue was especially apparent in efforts to write about the cyclic, iterative process that often occurs with improvement interventions. SQUIRE 1.0 was seen by many as unnecessarily complex with too much redundancy and lacking a clear distinction between “doing improvement” and “studying the improvement.” A recent independent study and editorial also documented and addressed some of these challenges.20,21

In the second phase, we convened an international advisory group of 18 experts that included editors, authors, researchers, and improvement professionals. This group met through three conference calls, reviewed SQUIRE 1.0 and the results of the end-user evaluation, and provided detailed feedback on successive revisions. This advisory group and additional participants attended two consensus conferences in 2013 and 2014 where they engaged in intensive analysis and made recommendations that further guided the revision process.

In the third phase, 44 authors used an interim draft version of the updated SQUIRE guidelines to write sections of a manuscript. Each author then provided comments on the utility and understandability of the draft guidelines, and in their submitted section, identified the portions of their writing sample that fulfilled the items of that section.22 We also obtained detailed feedback about this draft version through semistructured interviews with 11 biomedical journal editors. The data from this phase revealed areas needing further clarification and which specific items were prone to misinterpretation. Finally, a penultimate draft was emailed to over 450 individuals around the world, including the advisory group, consensus meeting participants, authors, reviewers, editors, faculty in fellowship programs, and trainees. This version was also posted on the SQUIRE website with an invitation for public feedback. We used the information from this process to write SQUIRE 2.0 (Table 1).

SQUIRE 2.0

Many publication guidelines, including CONSORT (randomized trials), STROBE (observational studies), and PRISMA (systematic reviews) focus on a particular study methodology ( http://www.equator-network.org). In contrast, SQUIRE 2.0 is designed to apply across the many approaches used for systematically improving the quality, safety, and value of healthcare. Methods range from iterative changes using PDSA cycles in single settings to retrospective analyses of large-scale programs to multisite randomized trials. We encourage authors to apply other publication guidelines—particularly those that focus on specific study methods—along with SQUIRE, as appropriate. Authors should carefully consider the relevance of each SQUIRE item but recognize that it is sometimes not necessary, nor even possible, to include each item in a particular manuscript.

SQUIRE 2.0 retains the IMRaD (Introduction, Methods, Results, and Discussion) structure.23 Although used primarily for reporting research within a spectrum of study designs, this structure expresses the underlying logic of most systematic investigations and is familiar to authors, editors, reviewers, and readers. We continue to use A. Bradford Hill’s four fundamental questions for writing: Why did you start? What did you do? What did you find? What does it mean?24 In our evaluation of SQUIRE 1.0, novice authors found these questions to be straightforward, clear, and useful.

SQUIRE 2.0 contains 18 items but omits the multiple subitems that were a source of confusion for SQUIRE 1.0 users.19 A range of approaches exists for improving healthcare, and SQUIRE may be adapted for reporting any of these. As stated above, authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE item in a particular manuscript. In addition, authors need not use items in the order in which they appear. Major changes between SQUIRE 1.0 and 2.0 are concentrated in four areas: (1) terminology, (2) theory, (3) context, and (4) studying the intervention(s).

Terminology

The elaborate detail in SQUIRE 1.0 was seen by users as a both a blessing and a curse19: helpful in designing and executing quality improvement work but less useful in the writing process. The level of detail sometimes led to confusion about what to include or not include in a manuscript. Consequently, we made the items in SQUIRE 2.0 shorter and more direct.

A major challenge in the reporting of systematic efforts to improve healthcare is the multiplicity of terms used to describe the work, which is challenging for novices and experts alike. Improvement work draws on the epistemology of a variety of fields, and depending on one’s field of study, the same words can carry different connotations, a particularly undesirable state of affairs. Terms such as “quality improvement,” “implementation science,” and “improvement science” refer to approaches that have many similarities but can also connote important (and often-debated) differences. Other terms such as “healthcare delivery science,” “patient safety,” and even simply “improvement” are also subject to surprising variation in interpretation. To address this problem in semantics, we created a glossary of terms used in SQUIRE 2.0 (Table 2). The glossary provides the intended meaning of certain key terms as we have used them in SQUIRE 2.0 (Table 1). These definitions may be helpful in other endeavors but are not necessarily intended to be adopted for use in other contexts. Overall, we sought terms and definitions that would be useful to the largest possible audience. For example, we chose “intervention(s)” to refer to the changes that are made. We decided not to use the word “improvement” in the individual items (although it remains in the SQUIRE acronym) to encourage authors to report efforts that did not lead to changes for the better. Reporting well-done, negative studies is vital for the learning in this discipline.

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)a

Table 2:

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)

Theory

SQUIRE 2.0 includes a new item titled “rationale.” Biomedical and clinical research is driven by iterative cycles of theory building and hypothesis testing. Healthcare improvement work has not consistently based the planning, design, and execution of its programs solidly in theory, to the detriment of the work. For this reason, SQUIRE 2.0 explicitly includes an item devoted to theory, although we chose to use the broader and less technical label “rationale,” to encourage authors to be explicit in reporting formal and informal theories, models, concepts, or even hunches as to why they expected a particular intervention to work in a particular context. A plain language interpretation of “rationale” might be, “Why did you think this would work?” A recent narrative review of the nature of theory and its use in improvement describes the many types and applications of theory, and considers pitfalls in using and not using theory.12

The addition of the “Rationale” item is intended to encourage clarity around assumptions about the nature of the intervention, the context, and the expected outcomes. The presence of a well thought out rationale will align with appropriate measures and with the study of the intervention; it may also be the starting point for the next round of work. The “Summary” item in the Discussion section encourages authors to revisit the original rationale in the light of its findings and in the larger context of similar projects.

Context

SQUIRE 2.0 accepts “context” as the key features of the environment in which the work is immersed and which are interpreted as meaningful to the success, failure, and unexpected consequences of the intervention(s), as well as the relationship of these to the stakeholders (e.g., improvement team, clinicians, patients, families, etc.).13–16 Systematic efforts to improve healthcare should contain clear descriptions and acknowledgment of context, rather than efforts to control it or explain it away. SQUIRE 1.0 included context with items in all sections of the manuscript, but context did not rise to the level of a distinct item itself. SQUIRE 2.0 recognizes context as a fundamental item in the methods section, but its relevance is not limited to this section. In addition to affecting the development of the rationale and subsequent design of the intervention(s), context plays a key role in the iterations of intervention(s) and the outcomes. While it is often not simple to capture or describe context, understanding its impact on the design, implementation, measurement, and results make it a vital contributor in identifying and reporting the factors and mechanisms responsible for the success or failure of the intervention(s).

Studying the Intervention(s)

The study of the intervention is, perhaps, the most challenging item in SQUIRE. In the evaluation of SQUIRE 1.019 and in the pilot testing,22 many were perplexed by this item and its subelements. This item was intended to encourage a more formal assessment of the intervention and its associated outcomes. In SQUIRE 2.0, this section is called, “Study of the Intervention(s)” (Table 1).

“Doing” an improvement project is fundamentally different from “studying” it. The primary purpose of “doing” improvement is to produce better local processes and outcomes, rather than contribute to new generalizable knowledge. In contrast, the reason for “studying” the intervention is mainly to contribute to the body of knowledge about the efficacy and generalizability of efforts for improving healthcare. Both “doing” and “studying” are required for a deep understanding of the nature and impact of the intervention(s), as well as the possible underlying mechanisms. “Study of the Intervention(s)” focuses mainly on whether and why an intervention “works.” It should align with the rationale and may include, but is not limited to, preplanned formal testing of the proposed theory that the intervention(s) actually produced the observed changes, as well as the impact of the intervention(s) on the context in which the work was done.

SQUIRE 2.0 asks authors to be as transparent, complete, and as accurate as possible about reporting “doing” and “studying” improvement work, as both aspects of the work are key to scholarly reporting. The “Summary” and “Interpretation” items in the Discussion encourage authors to explain potential mechanisms by which the intervention(s) resulted (or failed to result) in change, thereby developing explanatory theories that can be subsequently tested.

Conclusions

The development of SQUIRE 2.0 consisted of a detailed analysis of SQUIRE 1.0, input from experts in the field, and thorough pilot testing. Many methods and philosophical approaches to improve the quality, safety, and value of healthcare are available. The systematic efforts to improve healthcare are often complex and multi-dimensional, and their effectiveness is inherently context dependent. SQUIRE 2.0 provides common ground on which the discoveries contributed by the various approaches can advance the field by sharing them in the published literature.

At the same time, we recognize that simply publishing SQUIRE 2.0 will not effect this change; additional efforts and resources are required. For example, we have created an explanation and elaboration (E&E) document (Goodman D, Ogrinc G, Davies L; personal communication, 2015) to accompany this article. For each item in SQUIRE 2.0, the E&E provides one or more examples from the published literature and a commentary on how the example(s) meets or does not meet the item’s standards; this information brings the content of each item to life. The SQUIRE website ( http://www.squire-statement.org) contains a number of resources, in addition to the guidelines themselves, including interactive E&E pages and video commentaries. The website supports an emerging online community for the continuous use, conversation about, and evaluation of the guidelines.

Writing about improvement can be challenging. Sharing successes, failures, and developments through scholarly literature is an essential component of the complex work required in order to improve healthcare services for patients, professionals, and the public.

References

  • Davidoff F, Batalden P. Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project. Qual Saf Health Care2005;14:319–25. doi:10.1136/qshc.2005.014787 [CrossRef]
  • DeVinney B, ed. Expanding Research and Evaluation Designs to Improve the Science Base for Health Care and Public Health Quality Improvement Symposium. Washington DC: Agency for Healthcare Research and Quality. Conference Summary, 15Sep2005.
  • Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood)2005;24:138–50. doi:10.1377/hlthaff.24.1.138 [CrossRef]
  • Grol RP, Bosch MC, Hulscher ME, et al. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q2007;85:93–138. doi:10.1111/j.1468-0009.2007.00478.x [CrossRef]
  • Rubenstein LV, Hempel S, Farmer MM, et al. Finding order in heterogeneity: types of quality-improvement intervention publications. Qual Saf Health Care2008;17:403–8. doi:10.1136/qshc.2008.028423 [CrossRef]
  • Davidoff F, Batalden P, Stevens D, et al. Publication guidelines for quality improvement in health care: evolution of the SQUIRE project. Qual Saf Health Care2008;17(Suppl 1):i3–9. doi:10.1136/qshc.2008.029066 [CrossRef]
  • Batalden P, Leach D, Swing S, et al. General competencies and accreditation in graduate medical education. Health Aff (Millwood)2002;21:103–11. doi:10.1377/hlthaff.21.5.103 [CrossRef]
  • Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington DC: Interprofessional Education Collaborative, 2011.
  • Teaching for Quality. 2013. https://www.aamc.org/initiatives/cei/te4q/ (accessed 21 Jun 2013).
  • Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook2007;55:122–31. doi:10.1016/j.outlook.2007.02.006 [CrossRef]
  • Nasca TJ, Philibert I, Brigham T, et al. The next GME accreditation system—rationale and benefits. N Engl J Med2012;366:1051–6. doi:10.1056/NEJMsr1200117 [CrossRef]
  • Davidoff F, Dixon-Woods M, Leviton L, et al. Demystifying theory and its use in improvement. BMJ Qual Saf2015;24:228–38. doi:10.1136/bmjqs-2014-003627 [CrossRef]
  • Bate P, Robert G, Fulop N, et al. Perspectives on context. London: The Health Foundation, 2014.
  • Kaplan HC, Provost LP, Froehle CM, et al. The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf2012;21:13–20. doi:10.1136/bmjqs-2011-000010 [CrossRef]
  • Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. BMJ Qual Saf2011;20(Suppl 1):i18–23. doi:10.1136/bmjqs.2010.045955 [CrossRef]
  • Taylor SL, Dy S, Foy R, et al. What context features might be important determinants of the effectiveness of patient safety practice interventions?BMJ Qual Saf2011;20:611–17. doi:10.1136/bmjqs.2010.049379 [CrossRef]
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  • Portela MC, Pronovost PJ, Woodcock T, et al. How to study improvement interventions: a brief overview of possible study types. BMJ Qual Saf2015;24:325–36. doi:10.1136/bmjqs-2014-003620 [CrossRef]
  • Davies L, Batalden P, Davidoff F, et al. The SQUIRE guidelines: an evaluation from the field, 5 years post release. BMJ Qual Saf2015. Published Online First: 18 Jun 2015. doi:10.1136/bmjqs-2015-004116 [CrossRef]
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Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Text Section and Item NameSection or Item Description
Notes to authorsThe SQUIRE guidelines provide a framework for reporting new knowledge about how to improve healthcare.
The SQUIRE guidelines are intended for reports that describe system level work to improve the quality, safety, and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s).
A range of approaches exists for improving healthcare. SQUIRE may be adapted for reporting any of these.
Authors should consider every SQUIRE item, but it may be inappropriate or unnecessary to include every SQUIRE element in a particular manuscript.
The SQUIRE Glossary contains definitions of many of the key words in SQUIRE.
The Explanation and Elaboration document provides specific examples of well-written SQUIRE items and an in-depth explanation of each item.
Please cite SQUIRE when it is used to write a manuscript.
Title and abstract
  1. TitleIndicate that the manuscript concerns an initiative to improve healthcare (broadly defined to include the quality, safety, effectiveness, patient-centeredness, timeliness, cost, efficiency, and equity of healthcare).
  2. Abstract

Provide adequate information to aid in searching and indexing

Summarize all key information from various sections of the text using the abstract format of the intended publication or a structured summary, such as background, local problem, methods, interventions, results, conclusions

IntroductionWhy did you start?
  3. Problem descriptionNature and significance of the local problem
  4. Available knowledgeSummary of what is currently known about the problem, including relevant previous studies
  5. RationaleInformal or formal frameworks, models, concepts, and/or theories used to explain the problem, any reasons or assumptions that were used to develop the intervention(s), and reasons why the intervention(s) was expected to work
  6. Specific aimsPurpose of the project and of this report
MethodsWhat did you do?
  7. ContextContextual elements considered important at the outset of introducing the intervention(s)
  8. Intervention(s)

Description of the intervention(s) in sufficient detail that others could reproduce it

Specifics of the team involved in the work

  9. Study of the Intervention(s)

Approach chosen for assessing the impact of the intervention(s)

Approach used to establish whether the observed outcomes were due to the intervention(s)

10. Measures

Measures chosen for studying processes and outcomes of the intervention(s), including rationale for choosing them, their operational definitions, and their validity and reliability

Description of the approach to the ongoing assessment of contextual elements that contributed to the success, failure, efficiency, and cost

Methods employed for assessing completeness and accuracy of data

  11. Analysis

Qualitative and quantitative methods used to draw inferences from the data

Methods for understanding variation within the data, including the effects of time as a variable

  12. Ethical considerationsEthical aspects of implementing and studying the intervention(s) and how they were addressed, including, but not limited to, formal ethics review and potential conflict(s) of interest
ResultsWhat did you find?
  13. Results

Initial steps of the intervention(s) and their evolution over time (e.g., time-line diagram, flow chart, or table), including modifications made to the intervention during the project

Details of the process measures and outcome

Contextual elements that interacted with the intervention(s)

Observed associations between outcomes, interventions, and relevant contextual elements

Unintended consequences, such as unexpected benefits, problems, failures, or costs associated with the intervention(s)

Details about missing data

DiscussionWhat does it mean?
  14. Summary

Key findings, including relevance to the rationale and specific aims

Particular strengths of the project

  15. Interpretation

Nature of the association between the intervention(s) and the outcomes

Comparison of results with findings from other publications

Impact of the project on people and systems

Reasons for any differences between observed and anticipated outcomes, including the influence of context

Costs and strategic trade-offs, including opportunity costs

  16. Limitations

Limits to the generalizability of the work

Factors that might have limited internal validity, such as confounding, bias, or imprecision, in the design, methods, measurement, or analysis

Efforts made to minimize and adjust for limitations

  17. Conclusions

Usefulness of the work

Sustainability

Potential for spread to other contexts

Implications for practice and for further study in the field

Suggested next steps

Other information
  18. FundingSources of funding that supported this work. Role, if any, of the funding organization in the design, implementation, interpretation, and reporting

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)a

Assumptions
Reasons for choosing the activities and tools used to bring about changes in healthcare services at the system level.
Context
Physical and sociocultural makeup of the local environment (e.g., external environmental factors, organizational dynamics, collaboration, resources, leadership, and the like), and the interpretation of these factors (“sense-making”) by the healthcare delivery professionals, patients, and caregivers that can affect the effectiveness and generalizability of intervention(s).
Ethical aspects
The value of system-level initiatives relative to their potential for harm, burden, and cost to the stakeholders. Potential harms particularly associated with efforts to improve the quality, safety, and value of healthcare services include opportunity costs, invasion of privacy, and staff distress resulting from disclosure of poor performance.25
Generalizability
The likelihood that the intervention(s) in a particular report would produce similar results in other settings, situations, or environments (also referred to as external validity).
Healthcare improvement
Any systematic effort intended to raise the quality, safety, and value of healthcare services, usually done at the system level. We encourage the use of this phrase rather than “quality improvement,” which often refers to more narrowly defined approaches.
Inferences
The meaning of findings or data, as interpreted by the stakeholders in healthcare services—improvers, healthcare delivery professionals, and/or patients and families.
Initiative
A broad term that can refer to organization-wide programs, narrowly focused projects, or the details of specific interventions (e.g., planning, execution, assessment)
Internal validity
Demonstrable, credible evidence for efficacy (meaningful impact or change) resulting from introduction of a specific intervention into a particular healthcare system.
Intervention(s)
The specific activities and tools introduced into a healthcare system with the aim of changing its performance for the better. Complete description of an intervention includes its inputs, internal activities, and outputs (e.g., in the form of a logic model), and the mechanism(s) by which these components are expected to produce changes in a system’s performance.17
Opportunity costs
Loss of the ability to perform other tasks or meet other responsibilities resulting from the diversion of resources needed to introduce, test, or sustain a particular improvement initiative.
Problem
Meaningful disruption, failure, inadequacy, distress, confusion or other dysfunction in a healthcare service delivery system that adversely affects patients, staff, or the system as a whole, or that prevents care from reaching its full potential.
Process
The routines and other activities through which healthcare services are delivered
Rationale
Explanation of why particular intervention(s) were chosen and why it was expected to work, be sustainable, and be replicable elsewhere.
Systems
The interrelated structures, people, processes, and activities that together create healthcare services for and with individual patients and populations. For example, systems exist from the personal self-care system of a patient to the individual provider–patient dyad system, to the microsystem, to the macrosystem, and all the way to the market/social/insurance system. These levels are nested within each other.
Theory or theories
Any “reason-giving” account that asserts causal relationships between variables (causal theory) or that makes sense of an otherwise obscure process or situation (explanatory theory). Theories come in many forms, and serve different purposes in the phases of improvement work. It is important to be explicit and well-founded about any informal and formal theory (or theories) that are used.

Dr. Ogrinc is Senior Associate Dean for Medical Education, Geisel School of Medicine at Dartmouth, Associate Chief of Staff for Education, White River Junction VA, White River Junction, Vermont, and Associate Professor of Community and Family Medicine, Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Davies is Senior Scholar, Quality Scholars Program, Department of Veterans Affairs Medical Center, White River Junction, Vermont, and Associate Professor of Surgery, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover New Hampshire; Dr. Goodman is Fellow, VA Quality Scholars Fellowship Program, and Instructor, Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Dr. Batalden is Active Emeritus Professor, Pediatrics and Community and Family Medicine, Geisel School of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire; Dr. Davidoff is Editor Emeritus, Annals of Internal Medicine, and Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; and Dr. Stevens is Adjunct Professor, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, New Hampshire, Editor Emeritus, BMJ Quality and Safety, London, United Kingdom, and Senior Fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Name and affiliation of members of the SQUIRE 2.0 advisory group: Davina Allen, Cardiff University, UK; Ross Baker, University of Toronto, Canada; Helen Crisp, Health Foundation, UK; Mary Dixon-Woods, University of Leicester, UK; Don Goldmann, Institute for Healthcare Improvement, USA; Steve Goodman, Stanford University, USA; Leora Horwitz, New York University, USA; Pam Ironside, Indiana University, USA; Peter Margolis, University of Cincinnati, USA; Paul Miles, American Board of Pediatrics, USA; Shirley Moore, Case Western Reserve University, USA; Peter Pronovost, Johns Hopkins University, USA; Lisa Rubenstein, University of California Los Angeles, USA; Gwen Sherwood, University of North Carolina, USA; Kaveh Shojania, University of Toronto, Canada; Richard Thomson, Newcastle University, UK; Charles Vincent, Imperial College London, UK; and Hub Wollersheim, Radboud University Medical Center, the Netherlands.

© 2015 BMJ Quality & Safety; licensee SLACK Incorporated. Originally published in BMJ Quality and Safety, Published Online First: 14 September 2015. doi:10.1136/bmjqs-2015-004411. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

This paper is being co-published in: American Journal of Critical Care, American Journal of Medical Quality, Canadian Journal of Diabetes, The Journal of Continuing Education in Nursing, Journal of American College of Surgeons, Journal of Surgical Research, Joint Commission Journal on Quality and Patient Safety, Journal of Nursing Care Quality, The Permanente Journal, GIMBE Evidence for Health (Italy), and MedWave (Chile).

This material is based on work supported by the Health Foundation (grant number 7099) and the Robert Wood Johnson Foundation (grant number 70024), and included the use of facilities and material at the White River Junction VA in White River Junction, Vermont.

Received: May 19, 2015
Accepted: July 17, 2015
Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication GuidelinesRevised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Table 1:

Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) Publication Guidelines

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)a

Table 2:

Glossary of Key Terms Used in Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0)

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