Understanding and optimising electronic audit and feedback to improve quality of care

Providing health professionals with feedback on their clinical performance (audit and feedback; A&F) is one of the most commonly used quality improvement strategies in healthcare. Although A&F interventions are generally effective, there is substantial variation in the observed effects, with a quarter of randomised trials of A&F finding little to no effect. This thesis aimed to advance the stagnant science of A&F through better understanding and optimising its ability to improve quality of care. We investigated (1) the theory and evidence underpinning A&F; (2) the impact of three state-of-the-art, theory and evidence-based electronic A&F interventions across different clinical settings on the quality of care; and (3) the mechanisms through which A&F affects health professionals’ clinical performance perceptions, improvement intentions, behaviour, and, ultimately, quality of care. We conclude that A&F helps because it guides health professionals to work on those quality aspects for which improvement is recommended, particularly through communicating low performance scores and making explicit performance comparisons to benchmarks, trends, or targets. However, professionals may not accept feedback, causing the feedback cycle to stop, if they: perceive the accuracy of the underlying feedback data to be low; disagree with benchmarks; or do not consider the clinical topic a relevant aspect of care quality. Health professionals who are confronted with performance feedback nevertheless often intend to reduce any indicated gaps between actual and recommended practice, but lack knowledge about improvement actions they could take, or they experience organisational barriers which inhibit translation of their intentions into actual change in clinical practice.