Background Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care. Methods A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context–mechanism–outcome configurations (CMOcs). Results From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration. Conclusions This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts. PROSPERO registration CRD42016039882.

IntroductionMany types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this proposed realist review are (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective. This protocol will provide the rationale for using a realist review approach and outline the method.Methods and analysisThis review will be conducted using an iterative four-stage approach. The first and second steps have already been executed. The first step was to develop an initial programme theory based on the literature that explains how audits are supposed to work. Second, a systematic literature search was conducted using relevant databases. Third, data will be extracted and coded for concepts relating to context, outcomes and their interrelatedness. Finally, the data will be synthesised in a five-step process: (1) organising the extracted data into evidence tables, (2) theming, (3) formulating chains of inference from the identified themes, (4) linking the chains of inference and formulating CMO configurations and (5) refining the initial programme theory. The reporting of the review will follow the ‘Realist and Meta-Review Evidence Synthesis: Evolving Standards’ (RAMESES) publication standards.Ethics and disseminationThis review does not require formal ethical approval. A better understanding of how and why these audits work, and how context impacts their effectiveness, will inform stakeholders in deciding how to tailor and implement audits within their local context. We will use a range of dissemination strategies to ensure that findings from this realist review are broadly disseminated to academic and non-academic audiences.PROSPERO registration numberCRD42016039882.

Healthcare professionals have to give substance to the role of a champion in order to successfully lead quality improvement (QI) initiatives. This study aims to unravel how hospitalists in training shape their role as a champion within the context of QI projects in hospital care and why some are more effective in leading a QI project than others. We focus on the role of credibility, as it is a prerequisite for fulfilling the role of champion. This multiple-case study builds upon 23 semi-structured interviews with hospitalists in training: quality officers and medical specialists. We first coded data for each case and then described the different contexts of each case in detail to enable comparison across settings. We then compared the cases and contrasted the attributes of credibility. Four attributes of credibility emerged and were identified as essential for the hospitalist in training to succeed as a champion: (1) being convincing about the need for change by providing supportive clinical evidence, (2) displaying competence in their clinical work and commitment to their tasks, (3) generating shared ownership of the QI project with other healthcare professionals, and (4) acting as a team player to foster collaboration during the QI project. We also identified two contextual factors that supported the credibility of the hospitalist in training: (1) choosing a subject for the QI project that was perceived as urgently required by the group of stakeholders involved, and (2) being supported by the board of directors and other formal and informal leaders as the leader of a QI project. Further research is needed to gain a deeper understanding of the relationship between credibility and sustainability of change.