Abstract
BackgroundAudit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals’ perceptions about their clinical performance and the influence of feedback on their intentions to change practice.MethodsWe conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals’ perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU’s own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard.ResultsWe analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0–100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic.ConclusionsAudit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals’ prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice.Trial registrationClinicalTrials.govNCT02922101. Registered 26 September 2016.
Highlights
Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most
Audit and feedback helps health professionals to work on aspects for which improvement is recommended
Given the abundance of professionals’ prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice
Summary
Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most. An empirical study showed that health professionals ignored between a third and half of the improvement recommendations when confronted with feedback on multiple quality indicators [6] This may indicate that health professionals already have certain perceptions about their clinical performance before receiving feedback, and that many times, feedback fails to change those perceptions. This potentially prevents professionals from developing intentions to improve their practice even if improvement is recommended, or, leads to retaining intentions to improve while there may not be room for improvement [10]. A lack of correspondence between health professionals’ intended improvement targets and recommended improvement targets may play an important role in explaining the limited effects of A&F interventions [3, 12]
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