Abstract
Quality improvement (QI) publication rates in pediatrics surged through the early 21st century yet have noticeably plateaued since that time, a paradoxical shift given the volume of ongoing improvement work across pediatric health systems. We propose that the gap lies not in the quality of work being performed but in the disconnect between rigorous local improvement and publishable scholarship. Key deficits include inadequately specified aims, absent or implicit theories of change, analytic approaches that cannot distinguish intervention-related improvement from routine variation, and insufficient attention to sustainability. Closing this gap requires renewed commitment to 4 foundational components through clear operational definitions and specific, measurable, achievable, relevant, time-bound (SMART) aims that signal prospective planning to reviewers, an explicit theory of change operationalized through a well-constructed key driver diagram, time-series analytic methods capable of demonstrating special cause variation attributable to the intervention, and demonstrated sustainability evidenced by replicable change rather than temporary disruption. Rigorous single-center QI with well-described context and an explicit theory of change remains the foundation of the field. Protecting its integrity is a shared responsibility among authors, mentors, journals, and health systems and is essential to advancing evidence-based care for children.