Perspective on Publishing Quality Improvement Efforts


Michael Kanter, MD; Patrick T Courneya, MD

Perm J 2017;21:17-140 [Full Citation]
E-pub: 10/13/2017


Quality improvement (QI) activities are critical to achieve the Triple Aim and to the Institute of Medicine’s six “Aims for Quality Improvement”: Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable. These QI activities are essential to create a learning health care system. Academic publishing is critical to foster continuous QI and sharing, and yet it tends to favor more traditional research articles. Publishing QI activities has great value, encourages greater rigor, and helps facilitate greater willingness to share improvement opportunities.


Quality improvement (QI) activities are critical to achieve the Triple Aim and to the Institute of Medicine’s six “Aims for Quality Improvement”: Safe, Effective, Timely, Patient-Centered, Efficient, and Equitable.1 These QI activities are essential to create a learning health care system,2 yet it is highly inefficient for each health care system to learn on its own without being informed by the experience of others. Academic publishing is critical to foster continuous QI and sharing. Although fields such as applied research and delivery science are emerging areas of inquiry, there is still a paucity of journals that publish QI activities and instead favor the more traditional research articles.

A challenge to those wanting to learn from prior quality efforts is getting good information about what was tried and what were the outcomes. Kaiser Permanente (KP) has a long history of discussing quality and performance improvement in national forums, first through Total Quality Management conferences, and since 2003, in what we currently know as the KP National Quality Conference. These meetings have always been designed with the intent to spread successful practices and learnings. Although successful, these meetings leave no permanent record of what was presented. Furthermore, quality leaders who cannot attend the meetings don’t have an easy way to access the learnings and don’t have a good way to assess the evidence behind the QI activities.

Often QI activities are undertaken in a Medical Center. After some evaluation is done, an attempt is made to spread the results through word of mouth using physician “champions” or other engaged clinicians. Then we wonder why best practices spread slowly. When looking at whether a QI project might be suitable for spread, one should critically examine the methodology. QI projects may be highly context dependent3 and thus not readily transferable. Because these occur outside of an experimental setting, there is a high risk of bias as compared with research studies.4 Because spread of a QI study may incur costs and command some organizational attention, one should be aware of how a QI project has been evaluated.5 Because randomization is usually not practical, QI studies may be conducted using a before-after design, time series, or stepped wedge design with greater potential for bias in the first and least in the latter.6 In some cases statistical adjustments may control for confounding variables in observational studies.7 Additional attention should be paid to data quality, whether the correct unit of analysis was used, and was followed-up long enough.7

Given the above, it behooves organizations that sponsor quality meetings to attempt to have presentations that describe the rigor of their studies and to encourage eventual publication. In trying to think through ways to better spread quality learnings, we enlisted The Permanente Journal to publish the abstracts of presentations from the KP National Quality Conference. There are many benefits to publishing these abstracts including 1) creating a permanent record of the quality projects, 2) forming a means of communicating both positive and negative outcomes from QI activities, 3) promoting more scientific rigor in designing and presenting QI activities, and 4) providing additional motivation for quality projects to be written and presented. Ideally, after going through the process of creating an abstract of publishable quality, authors would be encouraged to subsequently submit their work for publication in a peer-reviewed journal such as The Permanente Journal.

The 2017 KP National Quality Conference centered around the Institute of Medicine’s “Six Aims for Quality Improvement,” which our organization has adopted as our National Clinical Quality Strategy. In the spirit of continual improvement and striving to achieve these aims in everything we do, we hope that publishing the abstracts from this conference will encourage greater rigor and help facilitate greater willingness to share improvement opportunities both within and outside our organization. Perhaps this will also open the door to more academic publishing of QI projects. There is great value to learning from each other’s improvement attempts—even those that do not achieve their intended outcomes or do not stick.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Kanter M, Courneya PT. Perspective on publishing quality improvement efforts. Perm J 2017;21:17-140. DOI:

1.    Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health aff (Millwood) 2008 May-Jun;27(3):759-69. DOI:
2.    Grumbach K, Lucey CR, Johnston SC. Transforming from centers of learning to learning health systems: The challenge for academic health centers. JAMA 201 Mar 194;311(11):1109-10. DOI:
3.    Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S; SQUIRE Development Group. Publication guidelines for quality improvement in health care: Evolution of the SQUIRE project. Qual Safe Health Care 2008;17 Suppl 1:i3-i9. DOI:
4.    Thompson RG, Moss FM. QIR and SQUIRE: Continuum of reporting guidelines for scholarly reports in healthcare improvement. Qual Safe Health Care 2008 Oct;17 Suppl 1:i10-12. DOI:
5.    Auerbach AD. Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007 Aug 9;357(6):608-13. DOI:
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7.    Needham DM, Sinopoli DJ, Dinglas VD, et al. Improving the data quality control in quality improvement projects. Int J Qual Health Care 2009 Apr;21(2):145-150. DOI:


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