Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

Objectives: Utilization of emergency departments (EDs) for pediatric mental health (MH) complaints is increasing. These patients require more resources and have higher admission rates than those with nonpsychiatric complaints.Methods: A multistage, multidisciplinary process to reduce length of stay (LOS) and improve the quality of care for patients with psychiatric complaints was performed at a tertiary care children's hospital's ED using Lean methodology. This process resulted in the implementation of a dedicated MH team, led by either a social worker or a psychiatric nurse, to evaluate patients, facilitate admissions, and arrange discharge planning. We conducted a retrospective, before-and-after study analyzing data 1 year before through 1 year after new process implementation (March 28, 2011). Our primary outcome was mean ED LOS.Results: After process implementation there was a statistically significant decrease in mean ED LOS (332 minutes vs. 244 minutes, p < 0.001). An x-bar chart of mean LOS shows special cause variation. Significant decreases were seen in median ED LOS (225 minutes vs. 204 minutes, p = 0.001), security physical interventions (2.0% vs. 0.4%, p = 0.004), and restraint use (1.7% vs. 0.1%, p < 0.001). No significant change was observed in admission rate, 72-hour return rate, or patient elopement/agitation events. Staff surveys showed improved perception of patient satisfaction, process efficacy, and patient safety.Conclusions: Use of quality improvement methodology led to a redesign that was associated with a significant reduction in mean LOS of patients with psychiatric complaints and improved ED staff perception of care.ACADEMIC EMERGENCY MEDICINE 2016;23:440-447 © 2016 by the Society for Academic Emergency Medicine M ental health (MH) disorders are common in children, with an estimated 13%-20% of children in the United States experiencing a mental disorder in a given year.1-5 They also are increasing, with a reported 24% increase in inpatient MH and substance abuse admissions among children from 2007 to 2010 6 and an 80% increase in hospital stays for children with mood disorders from 1997 to 2010. 7 Despite this increasing prevalence, psychiatric services for children in many parts of the country are limited, 8 leaving many with unmet psychiatric care needs. 9Nationally, pediatric emergency department (ED) visits for MH issues increased by over 20% between 2001 and 2010. 10 Pediatric EDs (PEDs) have also seen high volumes of patients presenting with psychiatric crises, with 3.3% of PED visits related to MH issues in one

Lean I Quality improvement I Patient flow I Emergency medicine I Pediatrics I Continuous performance improvement I Process I Waste I Value Opinion statement In today's rapidly changing health care milieu, organizations are expected to continuously improve the quality of care delivered to an expanding population of patients. To do so, they need a framework for developing, testing and implementing changes. Lean provides a methodology to engage workers and leaders to identify waste in a process, develop standards, implement a change, assess the results of that change, review next steps, and repeat the process. This can be successfully accomplished in the highly variable world of emergency medicine and can help health care providers be more productive, engaged, and satisfied while enabling patients to receive the value-added care they want and expect. Successful implementation of Lean or any other improvement framework requires that the hospital and medical leadership are all strong supporters of the methodology, speak the same process improvement language and are able to generate support and resources for operation-wide forward movement.