Demonstration of publication and leading a successful closed-loop audit are both fundamental skills required of the modern ophthalmology trainee seeking to further their career. Both can seem like mammoth tasks with most publications failing to see the light of day and most audits failing to make a difference. However, it is possible to publish an audit or quality improvement project (QIP) allowing you to achieve both in one fell swoop. The path to achieve this objective can be treacherous which is why I have written the following top tips from bitter experience!
Tip #1 – Start with the end in mind: SQUIRE2.0 & identifying journals
In order to set off on the voyage to audit and publication nirvana, it is imperative to know where you intend to go. This serves as creating a structure in order to ensure you stay on track for both the audit or QIP and its subsequent publication. In this regard, it is therefore fundamental to read the Standards for Quality Improvement Reporting Excellence Guidelines V2.0 (SQUIRE2.0) (1). It is the gold-standard in the reporting for QIP and not only provides a structure for your manuscript but also lays out how to ensure that each part of your project Is of the highest standard.
A great project and manuscript deserve publication. It therefore merits identifying a number of journals where you may choose to submit. Journals which have published ophthalmology audits includes Orbit, European Journal of Ophthalmology, Clinical Ophthalmology, BMJ Open and Cureus. The key factors to identify will be: the types and styles of previous publications, publication fees, acceptance rate and publication time frame. These can all vary so it is worth identifying this beforehand.
Tip #2 – Getting going: Identify a problem
At the heart of every audit or QIP lies a problem. Keep your ears out for a problem that your seniors identify. This will most likely occur during morning handover or in between seeing patients during clinic. Senior colleagues can often become frustrated if standards are not being met. By listening out to such a grievance, not only will you have found a problem to target but also an invested mentor who will be motivated to assist you. Get to grips with the problem by creating a process map: a flow diagram depicting the patient journey and their interactions with the healthcare system (2). Consider where the problem arises in this pathway and who is involved at that point. This where you will mostly likely identify where the problem needs to be addressed and who needs to be involved.
Explore the issue further and try to identify if there is an associated guideline to the problem at hand. Try to crystalise and narrow the scope of the issue in order to maximize chances of success. Follow SQUIRE2.0 guidance and ensure that your problem actually exists by collecting qualitative or quantitative date to evidence it. Finally, convert the problem identified into a SMART aim (specific, measureable, attainable, relevant and time) bound e.g. improve glaucoma prescriptions at local GP practice by 30% in March 2022. Once you have done this, contact your local audit department and the clinical audit lead to ensure your audit is registered and you have an audit number and ethical clearance.
Tip #3 – Picking an intervention and implement
It is essential to ensure that the intervention you choose to implement will lead to the outcome you intend. You will need to be able to argue that this is the case when it comes to creating your manuscript. There are two primary ways in which this can be done. The first is create a Driver Diagram (3). This allows you to consider the contributing factors, “primary drivers”, to your problem and therefore overall aim. This provides a springboard to allow to brainstorm a number of intervention ideas which address these drivers. The second approach is to create a Pareto Chart (4). This is a process of quantifying comparing reasons as to why your problem exists and focusing on the most frequent cause. For example, the causes of incorrect glaucoma prescriptions could include wrong time, wrong eye, wrong dose. Data should be collated to identify the greatest cause and this should be the target of the intervention.
Once an intervention has been chosen, justified by the evidence above then this should be presented to the key stakeholders (5). These are individuals who can have the greatest impact realizing your intervention and for whom the intervention must be acceptable. Approach the key stakeholders with your intervention plan and collect their thoughts. It cannot be emphasized enough that by this stage you must have involvement of your patient population. When you implement your intervention, ensure that all your key stakeholders are aware. Finally, describe your intervention using the Template for Intervention Description and Replication (TIDieR) checklist for your submission (6).
Tip #4 – Monitor your change
A commonly used method to demonstrating change and by implication that your intervention has been successful is to undertake a snapshot data collection after the implementation of the intervention. However, doing so leads one vulnerable to have results do no demonstrate a new constant improvement. The best solution to this problem is to use Statistical Process Control (SPC) charts (7). It requires plotting data on a frequent basis to identify statistically significant trends in the outcome being measured. A simpler but similar method is the use of Run Charts (8). Both rely on data collection over an extended period of time to demonstrate cultural changes.
Tip #5 – Write it up, backwards
By following the above tips, you will likely have collected enough evidence in a way which demonstrates an effective improvement in your local ophthalmology service and with strong arguments as to why it was your intervention that lead to the change. Having already reviewed the SQUIRE2.0 guidelines, you will have a structure for your manuscript. Be sure to check the referencing requirements of the publication to which you are most likely going to submit. Ensure you are comfortable using a referencing tool such as EndNote or Zotero.
Starting to write can seem difficult. It is therefore recommended that you begin with the methods before moving on to results and discussion including interpretation and limitations. Before writing the conclusion, write the introduction, title and abstract. At this stage, read from start to finish to then write your conclusion. This is the moment to give your manuscript a couple of days to not be interfered and sent to colleagues prior to your final read-through and edit.
Once you have a manuscript ready, follow your publications guidance for submission. This can take longer than you may think so ensure you have provided yourself sufficient time to do so. There are often other documents that your publisher would want you to submit. This might include a letter to the editors. The letter should be brief and highlight three key points: (i) a brief description of the current context and the findings of your improvement projects (ii) the generalizability of the intervention and result and (iii) the reasons for selecting the journal to which you have submitted. After submission, your manuscript will undergo a peer-review process. The outcome of this will be you will be provided with feedback and questions from your reviewers. It is vital that you do not reject these comments but to implement changes and adjustments as required to your manuscript. Once this is done, you will write to the editor explaining how you have engaged with each of the suggestions made.
I hope the top tips to publishing your ophthalmology audit will lay out a structure which you can use to undertake your quality improvement project. Remember that the above are all tools to be used as you see best fit for the issue you have at hand. Nevertheless, it is worth undertaking a few fundamental steps to ensure you take your quality improvement project from the shop floor to the shop front.
1. Goodman D, Ogrinc G, Davies L, Baker GR, Barnsteiner J, Foster TC, et al. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Quality & Safety. 2016;25(12):e7-e.
2. ELFT. Flow Diagrams [Available from: https://qi.elft.nhs.uk/resource/flow-diagrams/.]
3. NHS. Driver Diagrams: NHS England and NHS Improvement; 2022 [updated 01/12/22. Available from: https://www.england.nhs.uk/wp-content/uploads/2022/01/qsir-driver-diagrams.pdf.]
4. ELFT. Pareto Chart [Available from: https://qi.elft.nhs.uk/resource/pareto-charts/.
5. NHS. Stakeholder Analysis: NHS; [Available from: https://www.england.nhs.uk/wp-content/uploads/2022/02/qsir-stakeholder-analysis.pdf.]
6. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.
7. NHS. Statistical Process Control Tool: NHS; [Available from: https://www.england.nhs.uk/statistical-process-control-tool/.
8. NHS. Run Charts [Available from: https://www.england.nhs.uk/wp-content/uploads/2021/12/qsir-run-charts.pdf.]