A qualitative study of the variable effects of audit and feedback in the ICU.
BACKGROUND
Audit and feedback is integral to performance improvement and behaviour change in the intensive care unit (ICU). However, there remain large gaps in our understanding of the social experience of audit and feedback and the mechanisms whereby it can be optimised as a quality improvement strategy in the ICU setting.


METHODS
We conducted a modified grounded theory qualitative study. Seventy-two clinicians from five academic and five community ICUs in Ontario, Canada, were interviewed. Team members reviewed interview transcripts independently. Data analysis used constant comparative methods.


RESULTS
Clinicians interviewed experienced audit and feedback as fragmented and variable in its effectiveness. Moreover, clinicians felt disconnected from the process. The audit process was perceived as being insufficiently transparent. Feedback was often untimely, incomplete and not actionable. Specific groups such as respiratory therapists and night-shift clinicians felt marginalised. Suggestions for improvement included improving information sharing about the rationale for change and the audit process, tools and metrics; implementing peer-to-peer quality discussions to avoid a top-down approach (eg, incorporating feedback into discussions at daily rounds); providing effective feedback which contains specific, transparent and actionable information; delivering timely feedback (ie, balancing feedback proximate to events with trends over time) and increasing engagement by senior management.


CONCLUSIONS
ICU clinicians experience audit and feedback as fragmented communication with feedback being especially problematic. Attention to improving communication, integration of the process into daily clinical activities and making feedback timely, specific and actionable may increase the effectiveness of audit and feedback to affect desired change.
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
Tasnim
T
Sinuff
Department of Medicine and Critical Care Program, Queens University, Kingston General Hospital, Kingston, Ontario, Canada.
John
J
Muscedere
Independent Qualitative Researcher, Toronto, Ontario, Canada.
Linda
L
Rozmovits
Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.
Craig M
CM
Dale
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada.
Damon C
DC
Scales
D000046:Academic Medical Centers; D003422:Critical Care / Q000592:standards* / Q000639:trends; D005260:Female; D000068156:Formative Feedback; D066296:Grounded Theory; D006764:Hospitals, Community; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000639:trends; D007407:Interviews as Topic; D008297:Male; D008485:Medical Audit; D009864:Ontario; D010348:Patient Care Team / Q000592:standards*; D036301:Qualitative Research; D011785:Quality Assurance, Health Care
Audit and feedback; Implementation science; Qualitative research; Quality improvement