title: Audit and feedback and clinical practice guideline adherence: making feedback actionable.
abstract: BACKGROUND
  As a strategy for improving clinical practice guideline (CPG) adherence, audit and feedback (A&F) has been found to be variably effective, yet A&F research has not investigated the impact of feedback characteristics on its effectiveness. This paper explores how high performing facilities (HPF) and low performing facilities (LPF) differ in the way they use clinical audit data for feedback purposes.
  
  
  METHODS
  Descriptive, qualitative, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low adherence to six CPGs, as measured by external chart review audits. One-hundred and two employees involved with outpatient CPG implementation across the six facilities participated in one-hour semi-structured interviews where they discussed strategies, facilitators and barriers to implementing CPGs. Interviews were analyzed using techniques from the grounded theory method.
  
  
  RESULTS
  High performers provided timely, individualized, non-punitive feedback to providers, whereas low performers were more variable in their timeliness and non-punitiveness and relied on more standardized, facility-level reports. The concept of actionable feedback emerged as the core category from the data, around which timeliness, individualization, non-punitiveness, and customizability can be hierarchically ordered.
  
  
  CONCLUSIONS
  Facilities with a successful record of guideline adherence tend to deliver more timely, individualized and non-punitive feedback to providers about their adherence than facilities with a poor record of guideline adherence. Consistent with findings from organizational research, feedback intervention characteristics may influence the feedback's effectiveness at changing desired behaviors.
authors.affiliation: Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston, Texas, USA. sylvia.hysong@med.va.gov
authors.forename: Sylvia J
authors.initials: SJ
authors.lastname: Hysong
authors.forename: Richard G
authors.initials: RG
authors.lastname: Best
authors.forename: Jacqueline A
authors.initials: JA
authors.lastname: Pugh