Raising expectations and defining boundaries in quality management scholarship: Strengthening the design,methodology,and reporting of quality-focused work

Introduction

Paramedicine is foremost a peer-reviewed journal committed to advancing the discipline and profession through the dissemination of high-quality, methodologically rigorous research. However, it does acknowledge the role quality management (QM) plays in shaping clinical practice, education, systems performance, and patient outcomes. While distinct from traditional research, QM, encompassing quality improvement (QI), programme evaluation (PE) and other quality-centred activities, ¹ has the potential to contribute valuable insights and contribute to establishing a culture of evidence-informed practice within paramedicine.

Recognising this potential, Paramedicine will consider high-quality submissions that arise from QM work, provided they meet scholarly standards and are anchored to and contribute meaningfully to the literature. This is not a call for QM submissions, rather an acknowledgement that in some circumstances scholarly work done in this way can provide valuable insights for the community to consider, particularly in evolving or problematic spaces. While QM work is itself a robust science, with its own conventions and literature, its application, and ultimately reporting and submission for publication in Paramedicine has revealed some challenges. Some research-focused journals simply exclude QM contributions, while others have experienced and successfully navigated through similar territory; we align with the latter approach and therefore have determined to chart our own path in alignment with our vision.

While it is beyond the scope of an editorial to provide a comprehensive treatment of the topic, this editorial aims to provide some clarity on the distinction between research and QM to guide authors in positioning their work appropriately. Second, we share some common issues observed in QM submissions to the journal, with the hopes of avoiding common pitfalls in the future. Third, we offer some practical recommendations for enhancing the rigour, relevance, and reporting of QM initiatives submitted for publication.

Distinguishing quality management from research

In theory, the distinction between research and QM work is clear; however, in practice, the boundary is often blurred as many initiatives exhibit characteristics of both, creating the potential for individual and institutional uncertainty. ²

Before turning to research, it is important to clarify the distinctions within QM—particularly between QI and PE. Although related, these are distinct approaches within the broader domain of QM, which also includes quality assurance (QA) and quality measurement. While QA and quality measurement are discussed less frequently, they remain essential to system oversight and performance monitoring.

Program evaluation focuses on understanding how well a specific programme or initiative functions within its context, including its merit or value. It commonly uses models like CIPP, ³ Logic Models, ⁴ and Kirkpatrick ⁵ to generate a comprehensive understanding of the design, implementation, effectiveness and outcomes of a programme. Its aims include informing decision makers, supporting accountability, fostering learning and improvement, optimising resource allocation, and understanding what works, what doesn’t and why, often using methods consistent with research. ¹ The outputs of PE are generally intended to guide learning and decision making, often with potential relevance beyond the original context.

In contrast, QI is primarily action-oriented and aims to achieve new performance levels at the local level through iterative cycles of testing and refinement, commonly using tools such as the Model for Improvement, ⁶ Lean, ⁷ and Six Sigma. ⁸ The output of QI is measurable, sustained, localised system improvement within local settings, rather than generalisable knowledge or insights. ¹

In contrast to both QI and PE, research is defined by its intent to contribute or generate broadly applicable knowledge, emphasising generalisability in quantitative research paradigms or transferability in qualitative research paradigms. ⁹ It aims are broader in scope, often involving dissemination beyond the local context and adherence to methodological standards that support theory building or hypothesis testing.

Our experience with QM submissions

Our experience with QM submissions has identified several prominent issues that serve to diminish competitiveness for publication and strength of evidence: methodology, reporting, and ethical governance.

First, we find that QM submissions all too often appear to be those in name only. That is, there is often little demonstrable engagement with recognised QI or PE methodological frameworks nor positioning of the work within a paradigm of quality. Calling one's work QI or PE does not make it so; engaging tangibly with established methodology, and positioning it within a conceptual paradigm of quality, does. As a result, when a QI-specific quality appraisal instrument is applied in evaluation of these submissions, for example, the QI Minimum Quality Criteria Set (QI-MQCS) by Hempel et al., ¹⁰ most submissions do not fare well.

Second, we find that reporting of QI and PE frequently lacks essential reporting elements that enable demonstration of methodological rigour and inform critical appraisal. This may be in part because many are written in a manner that attempts to align more with research conventions than with QM. These submissions often adopt research-oriented language, emphasising generalisability rather than actionable applicability. As a result, some submissions are indistinguishable from research other than the label given and the absence of documented ethical approval, satisfying neither approach fully. That is, because the underlying work is quality in nature (i.e., different in intent and use, epistemology, pragmatic focus), fundamental features of robust research or QM can be lacking. This blurring, or lack of clarity or consistency with standards for the actual approach may reflect uncertainty or limited exposure to QM-specific frameworks and reporting standards, particularly in fields where methodological expectations vary.

Third, we find the status of QI and PE submissions in terms of ethical approval to often be ambiguous and on occasion ill conceived. Our sense is that there is a belief that projects labelled as such are inherently absolved of the need to demonstrate adherence to fundamental principles of ethical governance and external scrutiny by a human research ethics committee (HREC), Institutional Review Board (IRB), or equivalent. We commonly see the issue of ethical considerations in manuscripts seemingly waved away by authors with a simple statement claiming that because the study is deemed by the authors to be QI or PE, ethical approval was not necessary. While it is certainly true that many QI and PE projects can be exempted from HREC approval, this would be determined by a project's methodological design rather than the name given to it. ¹¹ For example, QI projects involving randomisation, novel procedures, or excess burden on patients may and often do require ethical review. ¹² They are certainly not exempt from a priori internal governance and review, which should be sufficiently sophisticated in procedure to discriminate between what does and does not need referral to a HREC regardless of the methodological design in question or the nomenclature used. ¹³

Strategies to enhance quality

Paramedicine, like other journals, has specific expectations aligned with its unique purpose and readership. Submitting a manuscript to Paramedicine as one would to another journal risks overlooking these distinctions and can reduce the likelihood of acceptance. The same principle applies when submitting to any other journal – alignment with a journal's specific focus is essential for success. With this in mind, we offer the following guidance to researchers considering submitting QM studies to our journal.

First, ground the quality work theoretically and conceptually, and connect to broader conversations in the literature within and adjacent to the discipline. In Paramedicine, QM submissions are not exempted from these expectations, and we direct authors to previous editorials by Brydges et al. ¹⁴ and Tavares et al. ¹⁵ for guidance on how to achieve this. An exemplar of this approach useful to prospective authors is the work by Johnston et al. who adopted an implementation science perspective and applied the a ‘Capability, Opportunity, Motivation and Behaviour’ (COM-B) model to their work evaluating implementation of intranasal ketamine in a Canadian jurisdiction. ¹⁶ We note that this process is not retrospective, done simply to match a paper to this journal's requirements prior to submission. Exploring the theory and concepts that are specific to or aligned with quality domains when designing a project and engaging deeply with the scholarly literature during planning and development, engagement and dissemination, strengthens the work; this should be articulated as part of the manuscript.

Second, engage sincerely and fully with QM methodology from the outset during design. QM as a scientific endeavour carries its own conventions, best practice guidelines and expectations. Early in the process, reflect on the project team's expertise and collaborate outside the discipline if necessary to ensure these strategies are followed. ¹⁷ Methodological expertise will ensure quality and enable more rigorous reporting when creating a manuscript. Paramedicine places a high premium on methodological quality, as it ultimately speaks to the legitimacy of the contribution that can be made to the discipline and potential for real impact. ¹⁸

Third, engage meaningfully with ethical governance during development and design with an authentic goal of avoiding harm and reducing risk to participants and interest holders. ¹⁹ Don’t assume ethical review is not applicable due to the work being in the QM space, and avoid decisions about seeking ethical review based on whether you intend to publish or not. Engage authentically with guidance on ethical review for QM projects available from most national research ethics organisations or that which is available in the extant literature. ¹⁹ To remove uncertainty, Paramedicine now requires evidence that a waiver of ethical approval was granted a-priori by an appropriate institutional ethics governance committee or HREC.

Finally, engage with related reporting guidelines where one exists. For QM submissions, Paramedicine endorses reporting guidelines such as the Standards for QUality Improvement Reporting Excellence (SQUIRE) reporting guidelines^20,21 or those for reporting evaluations based on observational methodology, ²² both freely available via the EQUATOR network (https://www.equator-network.org/), or others like these. While not without criticisms, reporting guidelines can enhance quality by providing a minimum and consistent set of essential reporting elements that increase transparency and completeness while allowing authors to keep their creative freedom.

Conclusion

Though first and foremost a research journal, Paramedicine will consider high-quality submissions reporting QM initiatives when they engaged in broader discourse, offer meaningful contributions to the paramedicine field and stimulate the paramedicine community to advance our thinking and understanding of a topic in a relatable way. We recognise that this raises expectations for the design, implementation and reporting of such work; however, we view this as a necessary step toward strengthening scholarship in our discipline. Submissions of this nature must be consistent with and apply these scholarly standards. Consistent with the journal's vision and mission, Paramedicine remains committed to promoting excellence not only in paramedicine research, but also in quality-focused initiatives that support system learning and improvement.