Contributions to the literature
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Providing quantitative summaries of clinical performance when treating specific groups of patients (“feedback”) is a widely used quality improvement strategy, yet it has varying success.
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Theory could help explain what factors influence feedback success; however, existing theories lack detail and specificity to health care.
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This is the first systematic review and meta-synthesis of qualitative evaluations of feedback interventions and presents the first comprehensive health care-specific feedback theory that can be used to design, implement, and evaluate feedback (Clinical Performance Feedback Intervention Theory; CP-FIT).
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Using CP-FIT could help improve care for large numbers of patients, reduce opportunity costs from unsuccessful interventions, and improve returns on feedback infrastructure investment.
Background
Example | |
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A group of clinicians choose a clinical topic on which to focus (e.g. sepsis, frailty), determine standards of care relating to that topic (e.g. patients with sepsis should receive antibiotics within 1 hour of diagnosis, all patients with frailty should have an annual medication review), then collect data to measure their current performance (e.g. from medical records), and calculate the proportion of patients meeting the standards. They present their findings to colleagues in a team meeting, and as a group they identify and implement changes. They re-measure their performance at a later date. | |
Health managers decide goals that are most important to their organisation (e.g. reducing hospital admissions, increasing vaccination uptake, reducing medication safety errors) and collect data to measure their current performance (e.g. from patient registries or administrative data). To account for the influence of patient characteristics, the results are adjusted for age and sex. These data are sent to health professionals as reports (e.g. electronic documents) and may also be made publically available. There may be financial rewards associated with achieving particular levels of performance. | |
Population-level data from electronic sources are automatically extracted and analysed across a range of topics (e.g. rates of antibiotic prescription, proportion of hypertensive patients with controlled blood pressure) to identify patients not receiving “optimal” care (e.g. from electronic health records). Results are continuously updated, and communicated via software to health professionals (e.g. as bar charts or line graphs via websites or desktop applications). |
Theory name and description | Covers the entire feedback process | Includes important factors in health care quality improvement | |||||
---|---|---|---|---|---|---|---|
Selecting clinical topics | Collecting and analysing data | Producing and delivering feedback | Making changes to clinical practice | Team-based change [5] | Context [123] | Intervention implementation [17] | |
Control Theory [14] | |||||||
Proposes that behaviour is regulated by a negative feedback loop, in which a person’s perception of their current state is compared against a goal. People strive to reduce perceived discrepancies between the two by modifying their behaviour. | No | No | No | No | No | No | No |
Goal Setting Theory [15] | |||||||
Explains how goals (defined as the object or aim of an action) affect task performance and how performance can be influenced by factors including commitment, goal importance, self-efficacy, feedback, and task complexity. | Yes | No | No | No | No | No | No |
Feedback Intervention Theory [16] | |||||||
Describes how feedback can influence behaviour and describes factors that determine whether feedback has a positive or negative influence on performance. Factors include feedback intervention cues; task characteristics; and situational variables (including personality). Feedback Intervention Theory draws upon ideas in both Control Theory and Goal Setting Theory. | Somewhat | No | Yes | No | No | No | No |
Aims and objectives
Methods
Search strategy
Study selection and data extraction
Inclusion criteria | Typical exclusion examples |
---|---|
Population
| |
The intervention primarily targeted health professionals (including clinicians and non-clinicians e.g. managers) [8]. | Interventions intended to help patients choose health care provider or treatment (e.g. [124]). |
Intervention
| |
The intervention provided feedback to participants [8]. | |
Feedback primarily concerned health professionals’ performance in clinical settings, defined as compliance with pre-defined clinical standards (e.g. clinical guidelines) and/or achievement of clinical patient outcomes [8]. This may have referred to the performance of an individual, their team, or organisation [8]. | Interventions that provided only fictitious feedback (e.g. [127]), feedback used in training or simulated settings (e.g. [128]), feedback on non-clinical aspects of performance, or data not directly related to clinical performance, such as costs of care (e.g. [129]), patient experience (e.g. [130]), or epidemiological surveillance (e.g. [131]). |
Feedback based only on peer or supervisor observation (e.g. [133]). | |
Dashboards that summarised patients’ current clinical status to primarily inform point-of care decisions (e.g. [138]). | |
Improvement collaboratives that primarily consisted of mentoring visits, improvement advisors, and educational sessions, with “benchmarking” as an additional component (e.g. [139]). | |
Comparator
| |
Not applicable | Not applicable |
Outcome
| |
The intervention primarily aimed to improve clinical performance (as defined) [8]. | Interventions that primarily intended to reduce costs (e.g. [129]). |
Study
| |
Studies of specific interventions described in enough detail to determine whether they met the above criteria. | Studies of groups or collections of interventions, the characteristics of which are not clearly described. For example, studies of “feedback interventions” in general (e.g. [140]). |
Evaluations of feedback interventions that reported both qualitative data collection (e.g. semi-structured interviews, focus groups, unstructured observations) and analysis methods (e.g. grounded theory, thematic analysis, framework analysis) [141]. They must have provided either a full methodological description or reference to a specific relevant approach [141]. Studies could seek to answer any research question about the feedback intervention. | Studies reporting interviews or focus groups but no description of analytic methods (e.g. [142]), intervention descriptions or protocol papers (e.g. [143]), editorials or opinion papers (e.g. [144]), quantitative surveys with or without open ended questions (e.g. [145]), or manuscripts with insufficient detail to judge adequacy, such as abstracts or letters (e.g. [146]). |
Peer-reviewed publications in scholarly journals written in English. | Books, grey literature, theses (e.g. [147]). |
Data synthesis
Results
Study characteristics
Count (%)* | |
---|---|
Publication date | |
2012–2016 | 42 (65) |
2007–2011 | 13 (20) |
2002–2006 | 4 (6) |
1996–2001 | 6 (9) |
Quality appraisal | |
No limitations | 0 (0) |
Minor limitations | 9 (14) |
Moderate limitations | 47 (72) |
Major limitations | 9 (14) |
Continent | |
Europe | 37 (57) |
North America | 22 (34) |
Africa | 2 (3) |
Australia | 2 (3) |
South America | 2 (3) |
Setting | |
Hospital inpatient | 30 (46) |
Primary care | 28 (43) |
Hospital outpatient | 3 (5) |
Nursing home | 3 (5) |
Mental health | 1 (2) |
Feedback topic | |
Chronic care (general) | 15 (23) |
Patient experience | 14 (22) |
Prescribing | 11 (17) |
Health care structures | 10 (15) |
General nursing | 8 (12) |
Surgery | 7 (11) |
Cancer | 5 (8) |
Diabetes | 5 (8) |
Stroke | 5 (8) |
Obstetrics | 5 (8) |
Preventive care | 4 (6) |
Infectious disease | 3 (5) |
Patient demographics | 2 (3) |
Staff experience | 2 (3) |
Intensive care | 2 (3) |
Mental health | 1 (2) |
General surgery | 1 (2) |
Heart failure | 1 (2) |
Orthopaedics | 1 (2) |
Paediatrics | 1 (2) |
Physiotherapy | 1 (2) |
Rheumatology | 1 (2) |
Care costs | 1 (2) |
Feedback recipient | |
Physicians | 45 (69) |
Nurses | 40 (62) |
Non-clinicians | 24 (37) |
Surgeons | 6 (9) |
Allied clinicians | 6 (9) |
Junior physicians | 3 (5) |
Midwives | 2 (3) |
Pharmacists | 2 (3) |
Pathologists | 1 (2) |
Radiologists | 1 (2) |
Feedback format | |
Paper report | 28 (43) |
Face-to-face | 25 (38) |
Software application | 12 (18) |
Electronic report | 10 (15) |
Co-intervention | |
Peer discussion | 28 (43) |
Problem solving | 22 (34) |
External change agent | 17 (26) |
Action planning | 15 (23) |
Reward (financial) | 13 (20) |
Clinical education | 7 (11) |
Reward (non-financial) | 5 (8) |
Reminders | 3 (5) |
Meta-synthesis: Clinical Performance Feedback Intervention Theory (CP-FIT)
Hypothesis: Feedback interventions are more effective when … | Relevant feedback cycle process(es) | Key explanatory mechanism(s) | Illustrative paper reference |
---|---|---|---|
Feedback variables
| |||
Goal | |||
1. Importance: … They focus on goals recipients believe to be meaningful and often do not happen in practice. | Acceptance, Intention | Compatibility, Credibility | |
2. Controllability: … They focus on goals perceived to be within the control of the recipients. | Acceptance, Intention |
Actionability
| [62] |
3. Relevance: … They focus on goals perceived as relevant to recipients’ jobs. | Acceptance, Intention | Actionability, Compatibility, Relative advantage | [64] |
Data collection and analysis method | |||
4. Conducted by recipients: … They do not require the recipient to collect or analyse the clinical performance data. (Can also decrease 41. Cost) |
Data collection and analysis
| Complexity, Resource match | [67] |
5. Automation: … They collect and analyse data automatically rather than manually. |
Data collection and analysis
| Complexity, Resource match | [68] |
6. Accuracy: … They use data believed by recipients to be a true representation of their clinical performance. |
Acceptance
| Credibility, Relative advantage | [50] |
7. Exclusions: … They allow recipients to exception report patients they feel are inappropriate to include in their performance measurement. |
Acceptance
| Actionability, Credibility | [70] |
Feedback display | |||
8. Performance level: … They communicate recipients’ current performance has room for improvement. | Intention, Behaviour | Actionability, Compatibility | [64] |
9. Patient lists: … They show the details of patients used to calculate the recipients’ clinical performance. | Verification, Acceptance, Perception, Intention, Behaviour |
Actionability
Complexity
Credibility
| [50] |
10. Specificity: … They report the performance of individual health professionals rather than their wider team or organisation. | Acceptance, Intention, Behaviour |
Actionability
| [72] |
11. Timeliness: … They use recent data to calculate recipients’ current performance. | Acceptance, Intention, Behaviour | Actionability, Credibility | [50] |
12. Trend: … They show recipients’ current performance in relation to their past performance. (Can also increase 40. Observability) |
Perception
| Complexity, Relative advantage | [73] |
13. Benchmarking: … They compare recipients’ current performance to that of other health professionals, organisations or regions. | Perception, Intention, Behaviour | Complexity, Social influence | [74] |
14. Prioritisation: … They communicate the relative importance of feedback contents. |
Perception
| Complexity, Relative advantage | [55] |
15. Usability: … They employ user-friendly designs. (Can also increase 40. Observability) |
Perception
|
Complexity
| [82] |
Feedback delivery | |||
16. Function: … They are perceived to support positive change rather than punish suboptimal performance. |
Acceptance
|
Compatibility
| [85] |
17. Source knowledge and skill: … They are delivered by a person or organisation perceived to have an appropriate level of knowledge or skill. |
Acceptance
| Credibility, Social influence | [86] |
18. Active delivery: … They “push” feedback messages to recipients rather than requiring them to “pull”. (Except if solely delivered face-to-face, which increases 41. Cost) |
Interaction
| Compatibility, Complexity | |
19. Delivery to a group: … They deliver feedback to groups of recipients. | Perception, Intention, Behaviour (by increasing 28. Teamwork) |
Social influence
| [98] |
Recipient variables
| |||
Health professional characteristics | |||
20. Feedback attitude: … They target health professionals with positive beliefs about feedback. | All | Compatibility, Relative advantage | [64] |
21. Knowledge and skills in quality improvement: … They target health professionals with greater capability in quality improvement. | Perception, Intention, Behaviour | Actionability, Complexity, Resource match | [91] |
22. Knowledge and skills in clinical topic: … They target health professionals with greater capability in the clinical topic under focus. | Perception, Intention, Behaviour | Actionability, Resource match | [92] |
Behavioural response | |||
23. Organisation-level and Patient-level behaviour: … Health professionals undertake changes involving the wider health care system rather than just individual patients in response to feedback. (Can also increase 24. Resource) |
Clinical performance improvement
|
Actionability
| [95] |
Context variables
| |||
Organisation or team characteristics | |||
24. Resource: … Organisations and teams have greater capacity to engage with them. (Can also increase 23. Organisation-level behaviour) | All |
Resource match
| [98] |
25. Competing priorities: … Organisations and teams have minimal additional responsibilities. | All | Resource match, Compatibility | [90] |
26. Leadership support: … They are supported by senior managers. (Can also increase 23. Organisation-level behaviour) | All | Credibility, Resource match, Social influence | [87] |
27. Champions: … They are supported by individuals in the organisation dedicated to making it a success. | All | Credibility, Resource match, Social influence | [68] |
28. Teamwork: … They are implemented into organisations or teams whose members work together towards a common goal. | Perception, Intention, Behaviour | Actionability, Resource match, Social influence | [72] |
29. Intra-organisational networks: … They are implemented into organisations or teams with strong internal communication channels. | Interaction, Perception, Intention, Behaviour | Actionability, Compatibility, Resource match, Social influence | [51] |
30. Extra-organisational networks: … They are implemented into organisations or teams that actively communicate with external bodies. | Perception, Intention, Behaviour |
Actionability
Resource match
| [86] |
31. Workflow fit: … They fit alongside existing ways of working. | All | Compatibility, Complexity | [64] |
Patient population | |||
32. Choice alignment: … They do not include patients who refuse aspects of care measured in the feedback in their calculations. | Acceptance, Intention | Actionability, Compatibility, Complexity | [105] |
33. Clinical appropriateness: … They do not include patients whose care cannot be safely optimised further. | Acceptance, Intention | Actionability, Compatibility, Complexity | [148] |
Co-interventions | |||
34. Peer discussion: … They encourage recipients discuss their feedback with peers. (Can also increase 28. Teamwork) | Perception, Intention | Complexity, Resource match, Social influence | [89] |
35. Problem solving: … They help recipients identify and develop solutions to reasons for suboptimal performance (or support recipients to do so). |
Perception
| Actionability, Compatibility, Complexity, Resource match | [90] |
36. Action planning: … They provide solutions to suboptimal performance (or support recipients to do so). | Intention, Behaviour | Actionability, Complexity, Resource match | [62] |
37. External change agents: … They provide additional staff to explicitly support its implementation. |
All
|
Resource match
| [94] |
Implementation process | |||
38. Adaptability: … They are tailored to the specific needs of the health care organisation and its staff. (Can also increase 31. Workflow fit) | All | Compatibility, Complexity | [69] |
39. Training and support: … They provide training and support regarding feedback (not the clinical topic under scrutiny). | Perception, Intention, Behaviour (by increasing 21. Knowledge and skills in quality improvement) | Actionability, Resource match | [91] |
40. Observability: … They demonstrate their potential benefits to recipients. | All |
Relative advantage
| [88] |
41. Cost: … They are considered inexpensive to deploy in terms of time, human or financial resources. | All |
Resource match
| [67] |
42. Ownership: … Recipients feel they “own” it, rather than it has been imposed on them. | All |
Compatibility
| [149] |
Proposition | Relevant explanatory mechanism(s) | Key example hypotheses* |
---|---|---|
1. Capacity limitations Health care professionals and organisations have a finite capacity to engage with and respond to feedback; interventions that require less work, supply additional resource, or are considered worthwhile enough to justify investment, are most effective. | Complexity Relative advantage Resource match | 5. Automation 15. Usability 18. Active delivery |
2. Identity and culture Health care professionals and organisations have strong beliefs regarding how patient care should be provided that influence their interactions with feedback; those that align with and enhance these aspects are most effective. | Compatibility Credibility Social influence | 1. Importance 6. Accuracy 13. Benchmarking |
3. Behavioural induction Feedback interventions that successfully and directly support clinical behaviours for individual patients are most effective. | Actionability | 2. Controllability 11. Timeliness 34. Problem solving |
Theory | Contributes to the following constructs … * |
---|---|
Context and implementation theories | |
Diffusion of innovations [108] | Variables: Observability Mechanisms: Compatibility, Complexity, Relative advantage |
Diffusion of innovations in health service delivery and organisation [65] | Variables: Champion, Extra-organisational networks, Intra-organisational networks, Leadership support, Resource, Workflow fit, Relevance, Function, Adaptability, Observability, External change agent, Peer discussion Mechanisms: Compatibility, Complexity, Relative advantage, Resource match |
Consolidated framework for implementation research [99] | Variables: Champion Competing priorities, Extra-organisational networks, Intra-organisational networks Leadership support, Resource, Cost, Workflow fit, Relevance, Function, Adaptability, Observability, External change agent, Peer discussion Mechanisms: Complexity, Relative advantage, Resource match, Compatibility |
Multilevel approach to change [96] | Feedback cycle processes: Behaviour Variables: Patient-level vs organisation-level |
Feedback theories | |
Individual Feedback Theory [48] | Feedback cycle processes: Feedback, Perception, Acceptance, Intention, Behaviour, Clinical performance improvement Variables: Controllability, Accuracy, Patient lists, Performance level, Specificity, Timeliness, Function Mechanisms: Credibility |
Feedback Intervention Theory [16] | Feedback cycle processes: Goal setting, Feedback, Acceptance, Behaviour Variables: Benchmarking, Performance level, Specificity, Trend, Active delivery, Problem solving, Action planning |
Control theory [14] | Feedback cycle processes: Feedback, Perception, Acceptance, Behaviour, Clinical performance improvement Variables: Performance level |
General behaviour change theories | |
COM-B System [61] | Variables: Feedback attitude, Knowledge and skills in clinical topic, Knowledge and skills in quality improvement, Importance, Performance level, Function, Ownership |
Motivation-Opportunities-Abilities Model [93] | Variables: Feedback attitude, Knowledge and skills in clinical topic, Knowledge and skills in quality improvement, Importance, Performance level, Function, Ownership |
Theory of Planned Behaviour [150] | Feedback cycle processes: Intention, Behaviour Variables: Feedback attitude, Importance, Controllability |
Goal setting and action planning theories | |
Goal setting theory [15] | Feedback cycle processes: Goal setting, Feedback, Behaviour Variables: Importance, Controllability, Performance level |
Guideline adherence theories | |
Cabana guideline model [103] | Variables: Choice alignment, Clinical appropriateness |
Guidelines interdependence model [104] | Variables: Choice alignment, Clinical appropriateness |
Motivation theories | |
Self-determination theory [60] | Variables: Intra-organisational networks, Teamwork, Importance, Delivery to a group, Function, Ownership, Peer discussion |
Psychological theories | |
Cognitive dissonance [56] | Variables: Performance level, Exclusions |
Cognitive Load Theory [83] | Variables: Prioritisation, Usability |
Self-Affirmation Theory [57] | Variables: Performance level |
Persuasion theory [78] | Variables: Champion, Intra-organisational networks, Leadership support, Teamwork, Benchmarking, Delivery to a group, Source knowledge and skill, Peer discussion Mechanisms: Social influence |
Cognitive fit theory [76] | Variables: Trend |
Locus of Control [63] | Variables: Controllability |
Self-Efficacy Theory [109] | Variables: Controllability, Observability |
Obedience to authority [151] | Variables: Leadership support, Source knowledge and skill |
Sociological theories | |
Social comparison theory [77] | Variables: Benchmarking Mechanisms: Social influence |
Reference group theory [79] | Variables: Intra-organisational networks, Teamwork, Benchmarking, Delivery to a group, Peer discussion Mechanisms: Social influence |
Normative Social Influence [100] | Variables: Champion, Intra-organisational networks, Teamwork, Delivery to a group, Peer discussion Mechanisms: Social influence |
Social Learning Theory [106] | Variables: Extra-organisational networks, Training and support, External change agent, Peer discussion Mechanisms: Social influence |
Social Norms Theory [152] | Variables: Benchmarking Mechanisms: Social influence |
Technology theories | |
Value chain of information [49] | Feedback cycle processes: Interaction |
Fit between Individuals, Task, and Technology framework [80] | Variables: Workflow fit, Usability, Cost, Training and support Mechanisms: Compatibility, Complexity |
Task-Technology-Fit Model [119] | Variables: Workflow fit, Training and support Mechanisms: Compatibility, Complexity |
Technology Acceptance Model [66] | Variables: Feedback attitude, Relevance, Usability Mechanisms: Relative advantage |
Model of Information Systems Success [81] | Variables: Usability Mechanisms: Relative advantage |
Number | Quote | CP-FIT constructs illustrated |
---|---|---|
1 | Physicians’ disagreement with the assessment process results in no action. When they feel performance is based on a small sample of patients that is not representative of the care they provide they ignore the feedback and do not take any action … “The N is incredibly tiny. These patients may not be representative of our typical patient, yet these numbers are taken very seriously.” (Author interpretation and participant quote of a feedback intervention in US primary care [50]) | Feedback cycle processes: Acceptance, Behaviour Variables: Data collection and analysis method Mechanisms: Credibility |
2 | Many participants argued that much quality assurance work is being done within the field of diabetes care. As a counterweight, many felt that conditions like hypertension and chronic obstructive pulmonary disease (COPD) were in more need of attention. (Author interpretation of a feedback intervention focusing on diabetes care in Denmark [82]) | Feedback cycle processes: Tunnel vision Variables: Importance Mechanisms: Credibility, Compatibility |
3 | All GPs interviewed highly valued the process of reviewing patients identified as receiving high-risk NSAID [non-steroidal anti-inflammatory drug] or antiplatelet prescriptions. “The topic is, I would go so far as to say, essential. I do not even think you can say it’s urgent. It’s essential that practices are doing this. They could be killing patients totally unnecessarily” (Author interpretation and participant quote regarding feedback on potential medication safety errors in Scotland[94]) | Feedback cycle processes: Acceptance, Intention Variables: Importance Mechanisms: Compatibility |
4 | The California physicians … [complained] strongly about the accuracy of the data on which their performance was judged... “I have 91 diabetics,” one explained, of whom 32 were reported as “missing either a haemoglobin A1C or an LDL or [to] have elevated levels from September to August ‘07.” But, when he went through the labs and charts, “just on the first two pages I found that six of them were incorrect” (Author interpretation and participant quote regarding feedback in primary care in the US [153]) | Feedback cycle processes: Verification, Acceptance Variables: Accuracy Mechanisms: Credibility |
5 | The informants suggested that the identities of the inappropriately treated patients should be revealed in prescriber feedback … “It was frustrating that I had a quality problem without being able to do something about it... (but)... I am not sure whether I actually have a quality problem” (Author interpretation and participant quote regarding feedback on medication prescribing in Denmark [154]) | Feedback cycle processes: Verification, Acceptance, Perception, Intention, Behaviour Variables: Patient lists Mechanisms: Credibility, Actionability |
6 | Interviewees expressed even greater scepticism about public reporting of performance data … “Sharing [performance data] with [patients] without the opportunity first to improve things might be viewed as punitive.” (Author interpretation and participant quote regarding hospital-based feedback on stroke in the US [155]) | Feedback cycle processes: Acceptance Variables: Function Mechanisms: Compatibility |
7 | No participants reported using the feedback to set specific goals for improvement or action plans for reaching these goals. Even when prompted, most participants could not envision ways for the practice to facilitate pro-active chronic disease management … (Author interpretation of feedback focusing on chronic diseases in Canada [90]) | Feedback cycle processes: Intention, Behaviour Variables: Knowledge and skills in quality improvement Mechanisms: Actionability, Resource match |
8 | Increased awareness of suboptimal performance usually resulted in the intention to “try harder” to do more during each patient visit, rather than “work smarter” by implementing point-of-care reminders or initiating systems to identify and contact patients for reassessment … Such findings help to explain the small to moderate effects generally observed in randomised trials of audit and feedback. (Author interpretation of feedback intervention focusing on chronic diseases in Canada [90]) | Feedback cycle processes: Intention, Behaviour, Clinical performance improvement Variables: Organisation-level behaviour, Patient-level behaviour Mechanisms: Actionability |
9 | In both interviews and observed meetings, the executive team expressed a deep commitment to ensuring the safety and quality of the services provided by the hospital. Members of the team identified the [feedback system] as a major strategic component of this commitment and made an accordingly heavy investment (approximately UK£25 million or US$38 million over ten years). (Author interpretation of a hospital-based feedback intervention in England [87]) | Feedback cycle processes: Nil Variables: Leadership support, Resource Mechanisms: Resource match, Social influence |
10 | That effective surgical site infection [SSI] prevention requires a team effort was a preponderant view … Interprofessional collaboration between clinicians, especially between surgeons and anesthesiologists, was invariably viewed as an integral part of the consistent application of best practices and, ultimately, the successful prevention of SSIs. (Author interpretation of a feedback intervention focusing on the reduction of surgical site infections in Canada [72]) | Feedback cycle processes: Behaviour (patient-level) Variables: Teamwork, Intra-organisational networks Mechanisms: Actionability, Compatibility, Social influence |
11 | Most providers (as well as some managers) expressed helplessness in their ability to respond [to feedback], especially when large proportions of the list consisted of challenging patients that, despite best efforts, could not achieve treatment goals …. the link between results and evaluation can be undermined when criteria … do not align with treatment guidelines, the latest evidence, and especially principles of patient-centered care. (Author interpretation of feedback focusing on diabetes treatment in US primary care [58]) | Feedback cycle processes: Intention, Behaviour (patient-level), Clinical performance improvement Variables: Choice alignment, Clinical appropriateness Mechanisms: Actionability, Compatibility, Complexity |
12 | An active and interactive approach was observed in teams A and B, reflected in the planning of regular team meetings for discussions of scores, possible problems and solutions, and appointing a responsible person to take action. This approach was lacking in teams C and D, as confirmed by the surgeon from team D: “We should have looked at the data more often and also discussed the results to discover weaknesses.” (Author interpretation and participant quote regarding feedback on breast cancer surgery in The Netherlands [62]) | Feedback cycle processes: Interaction, Perception, Intention, Behaviour Variables: Peer discussion, Problem solving, Action planning Mechanisms: Actionability, Compatibility, Complexity, Social influence, Resource match |
13 | In Cuba and Bolivia, clinicians saw improvements as a direct result of the audit. Clinicians therefore considered audit a worthwhile activity and found it to be a key motivational factor and facilitator in improving clinical practice. (Author interpretation of feedback targeting tuberculosis diagnosis in South America [97]) | Feedback cycle processes: Interaction, Intention Variables: Observability Mechanisms: Relative advantage |
The feedback cycle (research objective 1)
Feedback variables (research objective 2)
Recipient variables (research objective 2)
Context variables (research objective 2)
Mechanisms (research objective 3)
Propositions (research objective 4)
Discussion
Summary of findings
Applying CP-FIT in practice and research
Comparison to existing literature
Cochrane review finding: Feedback may be most effective when … | Potential explanation according to CP-FIT |
---|---|
… The health professionals are not performing well to start out with. | Low Performance level facilitates Intention and Behaviour because it increases Compatibility with recipients’ personal views (i.e. that they want to provide high quality patient care) and Actionability (i.e. low performance implies room for improvement). |
… The person responsible for the audit and feedback is a supervisor or colleague. | A supervisor or colleague is likely to be perceived to have greater knowledge and skill (Source—knowledge and skill), which facilitates Acceptance by increasing Credibility. |
… It is provided more than once. | Multiple instances of feedback are inherent to the feedback cycle (Fig. 3). |
… It is given both verbally and in writing. | Feedback that is actively “pushed” to recipients i.e. verbally (Active delivery) facilitates Interaction by reducing Complexity by ensuring the feedback received. However, solely providing feedback face-to-face (verbally) inhibits Interaction by decreasing Resource match as it requires significant time commitment from recipients, so is enhanced if also provided in other ways. |
… It includes clear targets and an action plan. | “Targets” in the Cochrane review equated to Benchmarking and Trend, both of which facilitate Perception, Intention, Behaviour by decreasing Complexity (making it easier for recipients to know what constitutes “good performance” and therefore what requires a corrective response) and increasing Social influence (stimulating recipients’ sense of competition). Action planning and Problem solving facilitate Intention and Behaviour by increasing Actionability (providing practical support on how to respond effectively to the feedback message) and Resource match (by addressing health professionals’ general lack of knowledge and skills to perform these behaviours). |
Brehaut et al. [11] | Ivers et al. [5] | CP-FIT variables |
---|---|---|
Address credibility of the information. | Data are valid |
Accuracy
Source—knowledge and skill
Function
|
Delivery comes from a trusted source |
Source—knowledge and skill
| |
Provide feedback as soon as possible and at a frequency informed by the number of new patient cases | Data are based on recent performance |
Timeliness
|
Provide individual rather than general data. | Data are about the individual/team’s own behaviour(s) |
Specificity
|
Provide multiple instances of feedback. | Audit cycles are repeated, with new data presented over time | Multiple instances of feedback are inherent to the feedback cycle (Fig. 3). |
Provide feedback in more than 1 way. | Presentation is multi-modal including either text and talking or text and graphical materials |
Active delivery
|
Choose comparators that reinforce desired behaviour change | The target performance is provided |
Benchmarking
Trend
|
Feedback includes comparison data with relevant others | ||
Recommend actions that can improve and are under the recipient’s control. | Targeted behaviour is likely to be amenable to feedback |
Controllability
Performance level
|
Recipients are capable and responsible for improvement | ||
Recommend actions that are consistent with established goals and priorities | Goals set for the target behaviour are aligned with personal and organisational priorities |
Importance
Relevance
Workflow alignment
|
Recommend specific actions | Goals for target behaviour are specific, measurable, achievable, relevant, time-bound |
Action planning
Problem solving
Peer discussion
|
A clear action plan is provided when discrepancies are evident | ||
Closely link the visual display and summary message | N/A |
Usability
|
Minimise extraneous cognitive load for feed- back recipients. | N/A |
Prioritisation
Usability
|
Provide short, actionable messages followed by optional detail. | N/A |
Patient lists
Prioritisation
|
Address barriers to feedback use. | N/A | CP-FIT in its entirety can be used to address barriers |
Prevent defensive reactions to feedback. | N/A |
Function
|
Construct feedback through social interaction. | N/A |
Peer discussion
|