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How to write up quality and improvement work

Fiona Moss, Jen Perry

Gothenburg April 2016

Objectives of this session

• To gain some knowledge of some writing skills

• To be aware of the needs of readers as customers

• To consider the benefits of structures for writing abstracts and papers

• To learn a process for writing about your work

Objectives of this Session

• To encourage you to plan and complete your QI project

• To encourage you to “write it up” for publication

• To start to write a project as structured abstract

Also perhaps : in this session

To show that writing can help your

thinking

Ernest Hemingway

It is none of their business that you have to learn to write: let them think that you were born that way.

Why write?

• To create a sense of completion

• So others may benefit from your work

• To get feedback

• To engage in discussion with others

• To advance your career?

• Etc…

Why bother to write well?• Writing is one of the communication skills.

• To communicate your message with clarity and accuracy

• To engage and stimulate your readers

• To help you reflect on your work

Readers as customers

• Your paper is not for you or your team

• It is for others

• It should be easily “accessible”

• Make it an “easy” read – for your readers….

• ..and…please….for your editors and reviewers…too…!

• Remember editors are “proxy” readers

Background

• There is a lot of good QI work “out there”

• It might help if shared/communicated

• Writing is way of communication

• Publication would help others

RED

SYSTEM

BUDWEISER

SET

Getting down to writing:

• Story

• Structure

• (Style)

Quick foray into matters of style!

• “Good prose is like a window pane…”

• Short sentences

• Nouns and verbs!

• Avoid purple prose

Journalists’ first lesson (borrowed from Kipling’s serving men)

• What, why and when

• and How and Where and Who

George Orwell (1)

“[Language] becomes ugly and inaccurate because our thoughts are foolish, but the slovenliness of our language makes it easier for us to have foolish thoughts.

George Orwell (2)

• Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.

• Never use a long word where a short one will do. • If it is possible to cut a word out, always cut it

out. • Never use the passive where you can use the

active. • Never use a foreign phrase, a scientific word, or a

jargon word if you can think of an everyday English equivalent.

• Break any of these rules sooner than say anything outright barbarous.

Strunk and White (1)

• Omit needless words

• Use the active voice

Example (1)

Data obtained from the audits were analysed. Significant problems in preoperative and postoperative care were identified. Review of pre-admission process identified significant delays in transfer of patients from A+E setting to the two wards with alternating admissions. Delay in physician input was identified and the high level of mortality was unacceptable. There was a need in the hospital for a more proactive culture in the managing of this condition

Example (2)

Data obtained from the audits were analysed. Significant problems in preoperative and postoperative care were identified. Review of pre-admission process identified significant delays in transfer of patients from the A+E setting to the two wards with alternating admissions. Delay in physician input was identified and the high level of mortality was unacceptable. There was a need in the trust for a more proactive culture in the management of this condition.

Example (3)

Our audit showed problems in both preoperative and postoperative care. Patients were slow to be admitted from the emergency department (to two separate wards) and physicians did not assess them promptly. As a result mortality was high.

Strunk and White (2)

• Make the paragraph the unit of composition: one paragraph to each topic

• As a rule start each paragraph with a topic sentence; end it in conformity with the beginning

Paragraphs

• Topic sentence: what’s the idea you want to talk about?

• Elaborate on that idea

• Final sentence: round off the point you are making….

• …and, ideally, form a link to the next idea

The other priority is infrastructure. Railways and roads, bridges and broadband give a bigger boost per pound from the public purse than other sorts of spending. Yet this is where cuts have been deepest…… projects do not need to be big: small, unglamorous improvements to roads, railways signals and the like can be started quickly. Investment could comfortably be doubled to £56 bn.

The tax system could also be changed to promote growth

Your story:

• Recall quality improvement work that you would like to share

• Write about it in just paragraph or two.

• Get it down to its “basics” – bullet points OK here

Instructions for ”readers/listeners”

• Listen very carefully….(!)

• Do you understand what the “story” is?

• What is missing that would help you understand?

• Write down any questions

Headlines: British tabloids

• We’d lose booze cruise if voters choose

Brexit

• We’re gonna Trump ship!

• Lend it like Beckham

• Broken glass costs pub landlord £18,000

Headlines: British tabloids

• NHS ready to sink £600m on Zumba classes

to cut fat docs' sickies

• Dope chief must quit: Athletics watchdog

told about dodgy doc two years ago

• Secret billions of top tax dodgers exposed

as the biggest leak EVER hits the rich

“Readers/listeners”

• Now write the “Sun headline”

Authors

• Is that “Sun headline” a correct summary?

Authors now revise your bullet points into paragraph(s)

• Listen to the play- back/questions from your readers.

• Be clear about “What is the ‘story’? “

• Revise your brief description of your quality improvement work

• Make sure that you make the main messages clear.

Using a structure (i)

• Structure (i.e. headings) can help the process of writing

• Useful for “marshalling” thoughts

• Headings – and sub headings – help “signal” the writers’ intention to the readers

• Make sure that you use the structure that fits your type of paper or abstract and the journal or conference.

Using a structure (ii)

• Structure provides a logical sequence

• Contains “the story” within it

• It needs to have a “thread” going back the stated written objectives

• Continuity between sections is important

• So, the ending should connect with beginning i.e. “discussion” or equivalent should relate to

“introduction”

The procedure is actually quite simple. First, you arrange

things into different groups depending on their makeup. Of

course, one pile may be sufficient depending on how much

there is to do. If you have to go somewhere else due to lack

of facilities that is the next step, otherwise you are pretty well

set. It is important not to overdo any particular endeavour.

That is, it is better to do too few things at once than too many.

In the short run this may not seem important, but complications

from doing this can easily arise. A mistake can be expensive

as well. The manipulation of the appropriate mechanisms

should be self-explanatory, and we need not dwell on it here.

At first the whole procedure will seem complicated.

Doing Laundry

Writing about QI work should reflect:

• Cyclical nature of QI

• Process of assessment

• Relevance to patients and their care

• Process of gaining understanding of organisational issues

• Complexity of organisational change

• Impact on staff

• Steps required for organisational change

• Processes of review and re-assessment

A Structure for quality improvement

• The context• Outline of problem (patient centred) • Key measures of improvement• Process of gathering information about problem • Analysis and interpretation – how the

information helped your understanding of the problem/solution

• Strategy for change; implementation of change • Effects of change - reassessment• Next steps - lessons learnt – messages for others

Now….

• Take the 2 paragraphs you wrote about your quality improvement report , remembering the input from your “reader”

• Revise it using the structure provided…..

Your structured abstract

• Does this help?

• Could you convey your messages using this structure?

• What are the problems?

• Could you write your story for your reader?

Publishing QI work

Quality improvement reports for publication

• Must have a clear message for others

• Should be explicit about context

• Should include detail of how you managed to get and to sustain change in practice

• Organisational changes - details important

• Interpersonal interactions – details important

• Real message may lie in any difficulties don’t shy away from this

• Progress may not be linear – so write it this way

Convincing others

• Narrative important but not all

• Measurement and data are essential

• Need data that is robust

• But clearly QI is not RCT

• Beware spurious use of statistics

• How do you know your change is improvement

Where (i.e., for whom) do you want to publish?

• Decide on your target audience:

• Researchers? Teachers? Administrators?

• Specialty? Generic?

• Local? National? International?

What type of paper reflects your work?

• A quality improvement report?

• A research paper?

• A review?

• A “How To Do It?”

• An opinion/view point?

• A letter?

• .etc etc etc .....

Quality improvement reports for publications: the essentials

• Is it about improving the quality of care?

• Does it have a message relevant to improving the quality or safety of patient care?

• Does it describe changes that improve patient care?

• Is the evidence robust?

• Is it context specific?

• Or, are the messages generalisable?

• What is in it for others to learn?

Titles and Abstracts

• Usually the first (and possibly the only sections read

• So your best marketing tool

• Make sure you know your core message and that it comes through

•

Squire Guidelines:

• Introduction

• Background knowledge

• Local problem

• Intended improvement

• Study question

• Methods

• Ethical issues

• Setting

• Planning intervention

• Planning study of intervention

• Methods of evaluation

• Analysis

Squire Guidelines:

• Results

• Outcomes

– Nature of setting and improvement intervention

– Changes in processes of care and patient outcomes

• Discussion

• Summary

• Interpretation

• Relation to other evidence

• Limitations

• Conclusions

• Other factors

SQUIRE guidelines

http://www.squire-statement.org/guidelines

Standard structure for research papers :

• One standard structure for research papers . “IMRaD”

• Introduction/Methods/Results and/Discussion

• Not a helpful structure for QI work

IMRAD• Introduction

Why did you start?

• Methods

What did you do?

• Results

What did you find?

• Discussion

What does it mean?

Introduction

• Provide the necessary background for the paper

• Essentially “make the case” for what is coming

• Ends with the objectives of the paper –to which the whole of the rest of the paper is written

• Objectives must be clear and accurate – watch your words!

Methods

• Use headings and sub-headings to structure the methods (even if the journal does not)

• Make sure the order is logical

• Penultimate section “data analysis” – how did you use data to meet objectives and details of statistical (or other e.g. qualitative) did you take

• End with ethical committee permission

Results

• Headed sub-sections

• Helps with writing (can be taken out later)

• Logical order –start with demongraphics

• Must link to objectives

• Whole number with percentages in brackets x/y(n%)

Template for a discussion.

1. Compare /contrast your findings with any other relevant work in the field

2. Comment on the clinical or other implications of your findings

3. Compare and contrast your findings with other relevant work in the field

4. Out line the limitations of your work

5. Ending – e.g. a reflection on ideas for future work in your field

Discussion

• Short “pithy” summary of main findings –must link to objectives

• Outline of clinical or other implications

• If appropriate compare results with other relevant work

• Outline limitations of work

• Reflect on possible future research

Research

• Many journals have moved on from IMRAD

• Reporting statements – e.g. CONSORT, STROBE

• Structured abstracts

Structured abstract for RCT

• Objective

• Design

• Setting

• Participants

• Interventions

• Main outcome measures

• Results

• Conclusions

Which section of a paper is most important?

Writing other types of papers

Finding a structure

• What sort of article?

• Is there a ready made structure?

Look at the journal you want to publish in

• If not you are on your own SO

• Create a structure

• Perhaps start with: beginning/middle/end -

Finally:

• Write the paper

• Then put it in a drawer

• Take it out and edit it

• Give the paper to a “critical friend” to read

• Take all comments as “kaizen”

• The more you write the easier it becomes

• Take care over all writing – even emails

What to do if your paper is rejected

• Pout, curse, commiserate with co-authors

• Take some time away

• Appeals are possible, but pay particular attention to the editors’ commentary

• Use the feedback to revise for submission elsewhere and/or adjust your next study

What to do if you are offered the opportunity to revise

• Celebrate (but not too much)

• Take some time away

• Carefully attend to each point in the review, but pay particular attention to the editors’ commentary

• Submit a clearly marked revision along with a descriptive cover letter

To write well, you need to read

(specifically and broadly)

Keep in mind …

Your colleagues are your greatest asset

Keep in mind …

A journal’s main responsibilities are towards its readers,

not the authors

Keep in mind …