Enhancing national audit through addressing the quality improvement capabilities of feedback recipients: a multi-phase intervention development study

Abstract

Background National audits are a common, but variably effective, intervention to improve services. This study aimed to design an intervention to increase the effectiveness of national audit. Methods We used interviews, documentary analysis, observations, co-design and stakeholder engagement methods. The intervention was described in an intervention manual and illustrated using a logic model. Phase 1 described the current hospital response to a national audit. Phase 2 identified potential enhancements. Phase 3 developed a strategy to implement the enhancements. Phase 4 explored the feasibility of the intervention alongside the National Audit of Dementia and refined the intervention. Phase 5 adapted the intervention to a second national audit (National Diabetes Audit). Phase 6 explored the feasibility and fidelity of the intervention alongside the National Diabetes Audit and used the findings to further refine the intervention. Results The developed intervention is a quality improvement collaborative (QIC), containing virtual educational workshop, virtual outreach for local team leads and virtual facilitation of a learning collaborative delivered after feedback has been received. The QIC aims to support national audit recipients to undertake improvement actions tailored to their local context. The target audience is clinical and clinical governance leaders. We found that actions from national audit were constrained by what the clinical lead perceived they deliver personally, these actions were not aligned to identified influences upon performance. We found that the hospital response could be enhanced by targeting low baseline performance, identifying and addressing influences upon to performance, developing trust and credibility, addressing recipient priorities, presenting meaningful comparisons, developing a conceptual model, involving stakeholders and considering the opportunity cost. Phase 3 found that an educational workshop and outreach strategy could support implementation of the enhancements through developing coherence and cognitive participation. We found feasibility could be increased by revising the content, re-naming the intervention, amending activities to address time commitment, incorporating a more structured analysis of influences, supporting collaboration and developing local feedback mechanisms. Phase 5 found adaptation to a second national audit involved reflecting differences in the clinical topic, context and contractual requirements. We found that the behaviour change techniques identified in the manual were delivered by facilitators. Participants reported positive attitudes towards the intervention and that the intervention was appropriate. Conclusions The QIC supports local teams to tailor their actions to local context and develop change commitment. Future work will evaluate the effectiveness of the intervention as an adjunct to the National Diabetes Audit.

A commentary on the quality improvement practices in leading an organizational response to audit feedback

“…By describing practices in the organizational response, this paper aims to support feedback providers and quality improvement leads to consider influences upon the implementation of these improvement practices; for example, the barriers and facilitators to clinical leads engaging stakeholders or exploring influences upon clinical performance. Important barriers and facilitator to implementation included how feedback recipients differentiate the approach from current practice, how they work with others to organize themselves to participate in a new practice and how they buy-in to the new approach 7 . Theory-informed co-design work identified that implementation may involve demonstration of the practices, supporting feedback recipients to plan how and when to carry them out and a credible source communicating in favour of the practices 7 .…”

“…Important barriers and facilitator to implementation included how feedback recipients differentiate the approach from current practice, how they work with others to organize themselves to participate in a new practice and how they buy-in to the new approach 7 . Theory-informed co-design work identified that implementation may involve demonstration of the practices, supporting feedback recipients to plan how and when to carry them out and a credible source communicating in favour of the practices 7 . Creating both the physical opportunity (e.g.…”

“…Organizational commitment is developed through discussions and includes consideration of risks to priorities, notably regulatory, reputational and financial objectives 8 . Considering stakeholders’ priorities and presenting information linking the need for improvement and the proposed actions to those priorities may help to generate commitment 7 . For example, describing how the work influences patient wellbeing, efficiency and/or individual or organizational reputation may make it easier for stakeholders to commit to improvement.…”

“…Espoused organizational priorities are often documented in strategy or workplan documents; for example, national strategies to reduce inequalities, organizational visions, strategic goals to be high performing or ward mission statements to provide safe and effective care. Currently, clinicians may be unaware of these priorities 7 . Feedback recipients could seek conversations with people who might be aware of the local organizational priorities (e.g.…”

“…The action model specifies the quality improvement practices that inform, and develop commitment for, the response to audit feedback. The action model was then refined through feasibility and co-design studies aligned to two national audits (diabetes and dementia) 7 . The model describes practices to appraise information and generate change commitment and resonates with Weiner's organizational readiness to change theory 9 .…”