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Audit and Feedback

Audit and feedback mechanisms collect data on providers’ performance and then feed information back on their behavior. The feedback may include a comparison of individuals’ performance patterns with those of immediate peers, with aggregate data for large groups of providers, or with accepted standards. The audit and feedback process encompasses a wide variety of interventions, including performance review, supervisor assessment, medical record review, results generated by computerized information systems, self-assessment, and accreditation surveys. Feedback interventions assume that notifying individuals or groups about deviations from peer behavior or accepted clinical criteria will lead to improved performance.

Several studies have examined the effectiveness of audit and feedback, with mixed results. Small to modest improvements in compliance have been demonstrated in some studies, but not others. Feedback has been shown to be effective in reducing length of stay, use of unnecessary diagnostic tests, and number of prescriptions written and increasing adherence to cancer screening guidelines. Other studies have suggested that ongoing feedback, particularly from a respected colleague or academic authority, can be effective in increasing prescribing rates for generic drugs and compliance with protocols. Some authors have suggested that feedback may be particularly effective in increasing the delivery of preventive services: because physicians tend to overestimate the amount of preventive services they deliver, providing them with feedback on their actual performance may raise awareness about the need for behavior change. Individual, personalized feedback was found to be more effective than group feedback or unsolicited, unpersonalized feedback.

Supervisory audit using structured checklists to observe health worker performance or review records is one of the few audit and feedback interventions used widely in developing countries. Anecdotal evidence and the few published studies suggest that supervisory audit can be effective in increasing performance according to standards, particularly with respect to history-taking, physical examination, disease classification, treatment, and counseling. An operations research study by the Quality Assurance Project examined the impact of structured supervisory feedback on health worker adherence to IMCI standards for assessment, treatment, and counseling of sick children in Niger. The study found concluded that supervisory feedback had a significant short-term impact on IMCI performance, although the effect was not universal across all IMCI skill areas. Performance feedback from supervisors was found to have the greatest effect in areas where health workers were performing poorly.

Another variant of audit and feedback is self-audit or self-assessment. Self-assessment may be conducted by an individual health care provider, often as part of a continuing education activity to reflect on his or her own performance strengths and weaknesses in order to identify learning needs and areas for improvement. Self-assessment may also be conducted by a team, reviewing clinical records for a facility to measure performance across all providers in the facility as a whole. Improvement collaboratives typically rely on monthly team self-assessment of compliance with standards to track the effects of changes made to improve care.

Another type of audit and feedback approach that adds a social influence effect is peer review, which involves review of a provider’s performance by other providers of the same profession but who may practice in a different location.

Audit and feedback interventions based on peer review and support rely on the major role that colleagues’ judgment and beliefs play in an individual provider’s evaluation and interpretation of new information. Peer review uses the influence and pressure of persons in the target practitioners’ social network to affect individual performance. Peer-mediated strategies encompass a diverse group of interventions, including formal peer review, participatory guideline development, and team-based process improvement and problem solving. Several studies found that peer review was more effective in changing practice routines when it was used as part of a broader quality improvement approach that included participatory development of criteria, quality circles, or group discussion and feedback.

Because team-based peer review and support approaches tend to be directed at improving care within a facility as a whole rather than at the individual practitioner level, they may be more useful as part of strategies to achieve performance according to standards on an institutional level.

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