Authorship in Healthcare Improvement Projects: Principles and Practice

Why this topic matters

Fair and transparent authorship practices are fundamental to academic integrity and professional ethics. In healthcare improvement, where projects often involve multidisciplinary teams, clearly defined authorship criteria are essential for several reasons:

• Recognition: Authorship provides formal recognition for intellectual and practical contributions, which is important for career progression, appraisals, and revalidation (e.g., for trainees, consultants, and other healthcare professionals).
• Accountability: Authorship carries responsibility. Authors are accountable for the integrity of the work presented and should be able to defend its content.
• Collaboration: Clear guidelines foster positive team dynamics and encourage future collaboration by minimising disputes and ensuring all contributors feel valued.
• Dissemination: Properly attributed work enhances the credibility of findings when shared internally, at conferences, or in peer-reviewed journals.

Misunderstandings or disputes over authorship can damage professional relationships, delay dissemination, and undermine the credibility of the project outcomes.

Practical explanation: Defining authorship

Most guidelines for authorship, including those relevant to healthcare improvement, are based on criteria established by organisations like the International Committee of Medical Journal Editors (ICMJE). While originally designed for research, these principles are widely adopted for quality improvement (QI) and audit projects intended for publication or wider dissemination.

The ICMJE recommends that authorship be based on the following four criteria. All four criteria must be met to qualify as an author:

1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. This is the core intellectual and practical input.
2. Drafting the work or revising it critically for important intellectual content. This refers to writing the manuscript, report, or presentation, or providing significant intellectual revisions.
3. Final approval of the version to be published. All authors must agree to the final content and submission.
4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This underscores the responsibility that comes with authorship.

Individuals who contribute to a project but do not meet all four criteria should be acknowledged in an acknowledgements section rather than listed as authors. Examples include purely technical assistance, general supervision of a research group, administrative support, or providing resources. This distinction is crucial.

Order of authorship

The order of authorship should reflect the relative contributions to the work. While conventions can vary slightly by discipline, general principles include:

• First Author: Typically the individual who has made the most substantial intellectual contribution, often leading the project, data analysis, and manuscript drafting.
• Last Author (Senior Author/Guarantor): Often the most senior member of the team, the project supervisor, or the individual who takes overall responsibility for the integrity of the work and has often overseen the project from inception to completion, including securing funding or resources. This role often aligns with ICMJE criterion 4.
• Middle Authors: Ordered according to their decreasing contribution, or sometimes alphabetically if contributions are deemed equal.

It is vital to discuss and agree upon authorship order early in the project and revisit it as contributions evolve.

Common pitfalls

Several common issues can arise concerning authorship in improvement projects:

• Ghost Authorship: When individuals who meet authorship criteria are not listed as authors.
• Gift Authorship (or Guest/Honorary Authorship): When individuals who do not meet authorship criteria are listed as authors, often due to seniority or perceived influence. This is unethical and dilutes the recognition of actual contributors.
• Disputes over Order: Disagreements about the sequence of authors, particularly if not discussed and agreed upon upfront.
• Lack of Clarity: Unclear communication regarding roles and expectations, leading to assumptions about who will be an author.
• Changing Contributions: As projects evolve, an individual's contribution might change, necessitating a re-evaluation of authorship.

Step-by-step approach to managing authorship

Proactive communication and clear documentation are key to avoiding authorship disputes.

Step 1: Discuss and agree authorship criteria at project inception

• Initial Meeting: At the very beginning of the project, discuss potential authorship with all key team members.
• Define Roles: Clearly outline who will be responsible for each aspect of the project (conception, data collection, analysis, writing, oversight).
• Apply ICMJE Criteria: Explicitly state that authorship will be determined by the ICMJE four criteria. Explain these criteria to all team members.

Step 2: Document initial authorship agreements

• Written Agreement: Create a brief document or an email summary outlining the initial agreement on potential authors and their expected roles. This can be a simple table.
• Circulate and Confirm: Share this document with the entire team and ask for confirmation.
• Acknowledge Non-Authors: Also identify individuals who will contribute but are unlikely to meet authorship criteria and explain they will be acknowledged.

Step 3: Regularly review authorship during the project lifecycle

• Progress Meetings: Dedicate a small agenda item in regular project meetings to review contributions against the agreed criteria.
• Adapt as Needed: If roles or contributions change significantly, revisit the authorship discussion and update the documented agreement.
• Open Communication: Encourage team members to raise any concerns or questions about their contributions and potential authorship openly.

Step 4: Finalise authorship before submission/dissemination

• Pre-submission Review: Before drafting the final manuscript or report, have a dedicated discussion to confirm the final author list and their order.
• Circulate Draft: Share the complete draft with all proposed authors for their critical review and final approval, addressing ICMJE criterion 3.
• Confirm Accountability: Ensure all authors understand and accept their accountability for the work, fulfilling ICMJE criterion 4.
• Acknowledgements: Prepare a comprehensive acknowledgements section for all who contributed but do not meet authorship criteria.

Example in clinical practice

A multidisciplinary team at a large NHS Trust undertook a quality improvement project to reduce medication errors on a geriatric ward. The team included:

• Dr. Anya Sharma (Geriatric Registrar): Conceived the project idea, designed the intervention, led data collection and analysis, drafted the initial report. (Meets all 4 criteria)
• Ms. Beth Davies (Ward Manager): Provided significant input into intervention design based on ward practicalities, facilitated implementation, contributed to data interpretation. (Meets all 4 criteria)
• Mr. Chris Jones (Clinical Pharmacist): Advised on medication safety aspects, reviewed intervention design for pharmaceutical accuracy, contributed to discussion on implications. (Meets all 4 criteria)
• Dr. David Evans (Consultant Geriatrician/Clinical Lead): Provided overall project supervision, secured necessary resources, critically reviewed drafts, and gave final approval. (Meets all 4 criteria)
• Ms. Emily Frain (Staff Nurse): Assisted with data collection and staff training, but did not contribute to intellectual design or drafting. (Does not meet all 4 criteria)
• Mr. Frank Green (Data Analyst): Ran statistical tests requested by Dr. Sharma, but did not interpret findings or draft content. (Does not meet all 4 criteria)

Authorship Outcome:

• Authors: Dr. Anya Sharma (First Author), Ms. Beth Davies, Mr. Chris Jones, Dr. David Evans (Last Author).
• Acknowledgements: Ms. Emily Frain (for data collection and staff training support), Mr. Frank Green (for statistical analysis assistance).

This outcome reflects the intellectual and practical contributions in line with ICMJE guidelines, ensuring fair recognition and accountability.

How Lazomis can help

Lazomis provides a structured environment to manage your improvement projects, which can indirectly support clear authorship practices:

• Project Planning Tools: Our project setup and task management features allow you to clearly define roles and responsibilities for each stage of your improvement work. This helps in documenting who is leading specific aspects (e.g., data collection, analysis, report writing), which feeds into authorship discussions.
• Documentation Repository: All project documents, meeting minutes, and data analyses can be stored centrally. This provides a clear audit trail of contributions, making it easier to retrospectively assess who has met the ICMJE criteria.
• Communication Features: Integrated communication tools within Lazomis can facilitate transparent discussions about authorship at various project milestones, ensuring agreements are captured and accessible to all team members.
• Progress Tracking: By tracking individual and team progress on tasks, Lazomis can help provide objective evidence of contributions to the project, supporting fair authorship decisions.

Using Lazomis helps maintain an organised, transparent record of your improvement project, providing the foundational information needed for robust authorship discussions.

Key takeaways

• Authorship should be based on four criteria: substantial contribution (conception, data, analysis), drafting/critical revision, final approval, and accountability.
• All four ICMJE criteria must be met; otherwise, contributors should be acknowledged, not listed as authors.
• Discuss and agree upon authorship and order early in the project and document these agreements.
• Regularly review and update authorship agreements as project contributions evolve.
• Finalise the author list and order with full team consensus before dissemination or publication.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.