The Standards for Quality Improvement Reporting Excellence (SQUIRE) are international guidelines for quality improvement publications. The guidelines provide a framework to report knowledge obtained from quality improvement studies. SQUIRE guidelines 1.0 were first published in 2008, and SQUIRE 2.0 in 2015. In 2024, a group of healthcare simulation researchers worked for about two years to develop the SQUIRE-SIM Standards for Quality Improvement Reporting Excellence for SIMulation publication guidelines for simulation-based quality improvement projects. This HealthySimulation.com article by Content Manager Dr. Teresa Gore, PhD, DNP, APRN, FNP-BC, CHSE-A, FSSH, FAAN, will highlight the published guidelines for healthcare simulation quality improvement projects or research dissemination.
SQUIRE Publication Guidelines: Whatโs New in Version 2.0
The SQUIRE (Standards for Quality Improvement Reporting Excellence) Publication Guidelines provide a framework for reporting healthcare improvement initiatives in a systematic, transparent, and replicable manner. Initially released in 2008 (SQUIRE 1.0), the guidelines aimed to enhance the quality and clarity of scholarly reports related to quality improvement (QI) efforts in healthcare. However, as the field evolved, so too did the need for more practical, adaptable guidance.
SQUIRE 2.0, released in 2015, represents a significant revision focused on improving usability for both authors and reviewers. While the core intent of promoting rigorous, narrative-driven reporting remains unchanged, several key updates distinguish Version 2.0:
- Broader Scope: SQUIRE 2.0 accommodates a wider range of interventions beyond traditional Quality Improvement, which includes system changes, safety initiatives, and process redesigns.
- Improved Clarity: Ambiguous or technical terms in 1.0 were replaced with clearer, more accessible language.
- Flexible Structure: Unlike the rigid checklist of 1.0, SQUIRE 2.0 allows more flexibility in narrative flow while encouraging inclusion of essential elements.
- Enhanced Emphasis on Learning: The new version highlights reflective insights and learning.
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What is SQUIRE-SIM?
SQUIRE-SIM (Standards for Quality Improvement Reporting Excellence for SIMulation)
was published April 2025. These guidelines were available as an epub online ahead of print publication in August 2024.
With increased incorporation of simulation-based methodologies into quality improvement activities, standards for reporting on simulation-specific elements in healthcare improvement research are needed. The team followed established consensus process methodology to iteratively create simulation-based extensions for SQUIRE 2.0 reporting guidelines. Fifteen Steering Committee members, 59 experts in simulation and quality improvement research, and 86 consensus meeting attendees reviewed SQUIRE 2.0 reporting guidelines and ultimately recommended simulation-based reporting guidelines for 22 of the 41 SQUIRE 2.0 guidelines. The team created simulation-based extensions to SQUIRE 2.0 reporting guidelines to improve the quality and standardization of reporting on simulation-specific elements of healthcare improvement research.
Recommendations from the expert panel were brought to a consensus meeting where existing guidelines were reviewed and recommendations made. Steering Committee members reviewed all recommendations, reconciled differences, and made final recommendations, which were piloted by experienced simulation and quality improvement researchers. Differences in expert panel and consensus meeting recommendations were reviewed by the Steering Committee. Expert panelists identified six items that required simulation-based extensions, which consensus meeting participants did not.
For those items in which there was disagreement between the expert panel survey and consensus meeting participant recommendations, the Steering Committee reviewed the items, rationales provided by the expert panelists, and discussion notes from the consensus meeting to resolve the conflict. Ultimately, the Steering Committee included simulation-based extensions in the areas of: abstract, study of the intervention, measures, results, summary, limitations, and conclusions.
The final 22 simulation-based extensions to SQUIRE 2.0 are discussed and illustrated in the published article. The authors provided a detailed example of the recommended simulation-based extension guidelines for a simulation-based quality improvement project.
Key Changes and Contributions of SQUIRE-SIM
- Simulation-Specific Terminology
- Emphasis on Educational Outcomes and Learning Environments.
- Enhanced Contextual Reporting
- Integration of Debriefing and Reflexivity
- Application to Both Research and Improvement Work
Why Were SQUIRE-SIM Reporting Guidelines Needed?
SQUIRE-SIM builds on the foundation of SQUIRE 2.0 and introduces simulation-relevant constructs, outcomes, and contextual elements that better reflect the complexities and goals of simulation-based education and improvement. It enhances the quality, clarity, and reproducibility of simulation scholarship, supporting both educators and researchers to advance evidence-based simulation practices.
The increased application of simulation-based methodologies and techniques to quality improvement research necessitates these expanded reporting guidelines to standardize the information provided. The use of these simulation-based extensions will enable a greater understanding of the learning and generalizability of such projects to ultimately improve patient care and outcomes.
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Citation of This Publication
Stone, K. P., Rutman, L., Calhoun, A. W., Reid, J., Maa, T., Bajaj, K., Auerbach, M., Cheng, A., Davies, L., Deutsch, E., Harwayne-Gidansky, I., Kessler, D. )., Ogrinc, G., Patterson, M., Thomas, A., Doughty, C., and International Network in Simulation-Based Innovation, Research and Education SQUIRE-SIM Reporting Guidelines Investigators. (2025). SQUIRE-SIM (Standards for Quality Improvement Reporting Excellence for SIMulation): publication guidelines for simulation-based quality improvement projects. Simulation in Healthcare, 20(2), 71-80. DOI: 10.1097/SIH.0000000000000819
SQUIRE 3.0 Guidelines: Currently Under Development
The SQUIRE 3.0 Guidelines (currently under development) aim to reflect the continued evolution of the healthcare improvement field, with a focus on enhancing transparency, equity, and real-world impact in quality improvement (QI) reporting. While still in draft and consultation stages, early indications suggest that SQUIRE 3.0 will build upon the foundational goals of previous versions while addressing emerging priorities in healthcare systems research and implementation science. SQUIRE 3.0 aims to modernize quality improvement reporting by embedding equity, contextual awareness, and meaningful reflection into the scholarly narrative, ensuring that lessons learned are not only scientifically rigorous but socially relevant and actionable.
The anticipated purpose and focus of SQUIRE 3.0:
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Emphasis on Equity and Inclusion: SQUIRE 3.0 is expected to integrate health equity more explicitly into Quality Improvement reporting.
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Real-World Relevance and Implementation: The new version will likely promote more detailed reporting on contextual factors, adaptability, and implementation challenges, making the findings more applicable to real-world settings.
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Stronger Guidance on Reflexivity and Learning: Authors may be asked to reflect more critically on their assumptions, positionality, and what was learned to support honest reflection and continuous improvement.
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Interdisciplinary and Systems-Level Perspective: SQUIRE 3.0 may expand the reach beyond clinical Quality Improvement to include broader system-level changes that involve public health, informatics, and cross-sector collaboration.
