1. Benefits of improving and disseminating evidence on quality improvement projects

    Dear Editor,

    It was a great pleasure to read the article by F. Davidoff and P. Batalden published in October 2005 issue of the journal Quality and Safety in Health Care, pages 807–814. The article clearly pictures how failing to publish quality improvement (QI) may have several adverse implications hindering the overall medical quality improvement expected by consumers, accrediting agencies, federal agencies and other governmental bodies.

    Lack of compensation (Staker, 2003) and forbidding clinician from publishing results may not help them to apply quality improvement (QI) methodologies to continuously improve care as many academic institutions evaluate their performance based on publication which is quite obvious in research. QI studies typically consist of a series of small, interrelated, stepwise experiments allowing new knowledge at each step to be assimilated into the next step, and allowing “mid-course” corrections in the study if necessary. In contrast, clinical trials are typically large long term studies with new knowledge only coming at the end although monitored regularly to stop when an overwhelming benefit or harm found.

    By encouraging publication of good quality improvement initiatives and publication of such activities will benefit 1) the health care operations to provide better care, and 2) bring reformation in reporting research evidence. QI evidence-based management initiatives will enhance the level of reading, understanding and integrating research evidence which in turn will increase the demands for manuscripts to report scientific evidence transparently. Basing clinical trial results, Rembold, (1998) reported that to prevent a breast cancer death in 9 years the number needed to treat was 695 for women aged 60-69 where as it was 4576 for women aged 40-49. When patients are advised to go for preventative treatments clinicians providing such specific information will bring a better informed decision making for the overall society.

    Both QI and research are like two sides of the same coin and play a vital role in healthcare. “Generalizable knowledge” plays a key role in distinguishing between QI and clinical trials. However, not all clinical trials yield generalizable knowledge but some QI can indeed yield generalizable knowledge. Shewhart’s (1932) and Deming’s (1986) cycle of learning and improvement came from QI and is applicable to any QI study. Juran’s (1998) “Diagnostic Journey,” “Remedial Journey,” and “Hold the Gains” likewise have universal applicability ranging from large industrial companies to service-based enterprises including healthcare organizations. In spite of Title 45 CFR Part 46, Section 46.101(b) which clearly states that QI studies would be exempt from the IRB process, recognizing the importance of QI to improve healthcare, institutions trying to make an oversight process for difficult to distinguish projects is laudable (Kofke & Rie, 2003). Similarly, Baily (2005) recommended specialized QI IRB along with some administrative process to oversee QI projects.

    Setting up a registration and review process in order to improve publication standards for QI projects may also benefit in preventing most of the misunderstandings and misuse (Johnson, 2004; Grossberg, 2004) when new improvement ideas are brought forth. This will also increase number of meaningful projects and publications which in turn help create a QI culture inbuilt in their daily work processes as research. Publication of QI efforts will establish QI value for healthcare quality and therefore will increase potential to receive grants from granting agencies as both QI and research are essential societal goals.


    1. Baily M. The ethics of improving health care quality and safety: A hastings center report. The University of Texas M. D. Anderson Cancer Center, Oct 4th 2005.

    2. Davidoff F and Batalden P. Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project. Qual Saf Health Care 2005; 14: 319-325.

    3. Staker LV. Teaching performance improvement: an opportunity for continuing medical education. J Contin Educ Health Prof. 2003 Spring;23 Suppl 1:S34-52. \

    4. Grossberg M. Plagiarism and Professional Ethics—A Journal Editor's View, The Journal of American History, 2004;90(4):1333.

    5. Johnson SH. Who's idea is it?. Nurse Author Ed. 2004 Spring;14(2):1-4.

    6. Rembold CM. Number needed to screen: development of a statistic for disease screening. BMJ. 1998 Aug 1;317(7154):307-12.

    7. Shewhart WA. Statistical Method From the Viewpoint of Quality Control, the Department of Agriculture, 1939.

    8. Deming WE. (1986). Out of the Crisis. Cambridge, MA: Massachusetts Institute ofbTechnology, Center for Advanced Engineering Study

    9. Joseph M. Juran and A. Blanton Godfrey, Juran’s Quality Handbook, McGraw-Hill, 1998.

    10. Kofke WA & Rie MA. Research ethics and law of healthcare system quality improvement: The conflict of cost containment and quality. Critical Care Medicine. 31(3) Supplement:S143-S152, March 2003.

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  2. IMRaD as a model for quality improvement reports

    Dear Editor,

    In the Scandinavian countries we have a lot of discussions related to how to publish quality improvement work, and process oriented writing courses are ongoing. Therefore, this article comes on time. I really agree with the authors that a quality improvement report has to follow the IMRaD-model, and the Table 1 "Draft proposed guidelines for stronger improvement evidence" and Table 2 are really helpful and understandable, and will help me as a teacher and adviser of these courses. Thanks!!

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