Table 5 Context-mechanism-outcome configuration for the audit and feedback program theory

1. Ownership and buy-in

 Audits conducted by an external party but in partnership with local clinicians, to ensure staff have input into the process

Triggers a sense of ownership and buy-in, as clinicians recognise that the audit represents best practice

Trust in the process and capability developed for future audits conducted locally

2. Sensemaking of information feedback

 Local hospitals with leaders who promote a learning culture, open a conduit for clinicians to engage with the auditors and lead the development of improvement plans

Local clinicians are open to hearing about their performance against measures, and on reflection can integrate this information with local, codified knowledge and evidence by proxy, to make sense of the implications for those receiving care

Evidence for implementing changes is provided to clinicians to support their case for local site improvements and educational requirements

3. Motivation and social influence

 Provision of data from an external source that allows comparison and benchmarking across comparable hospitals

Facilitation from an external incentive, peer competition, or credible source

Can overcome external locus of control and trigger motivation to improve or maintain performance

4. Responsibility and accountability

 Repeated feedback and education provided at the point of care to passionate clinicians who can influence practice change

Clinicians assume responsibility for audited components of care

Audit and feedback become an ongoing process and is leveraged to gain managerial support for improvement activities

5. Rationalisation of the status quo

 Perceived lack of partnership in audit process: large number of audit variables used, wrong cohorts audited, unclear, conflicting or absent evidence for audit measures, system barriers to care delivery outside of clinicians’ control. Measures lack meaning and accuracy are considered an impost

Staff’s trust in the results is undermined and tend to focus on rationalising the status quo instead

Disengage from the process and pursue their own priorities from other means of performance measurement and existing practices

6. Perceptions of unfairness and concerns about data integrity

 Audits do not capture local workflows and/or system barriers and/or the uniqueness of local settings

Clinicians perceive the audit as an unfair and unachievable process that sets them up to fail

Focus on defending current practice rather than where things could be improved

Immature communication systems between executive and frontline staff for managing expectations and understanding of the implementation support agency’s role (clinicians can misinterpret the audit as a performance management process rather than a learning opportunity)

7. Improvement plans that are not followed

 One-off feedback delivered by an external Agency without sufficient time provided for clinicians to digest the information before making improvement decisions or a specific outline of support that could be provided by the external Agency

Feedback does not provide a meaningful foundation for quality improvement

Local hospitals continue working on their own improvement priorities

8. Perceptions of threats to professional autonomy

 Rigid criteria used for audit rather than broad principles of care that are not localised to the local hospital audience

Clinical leaders perceive feedback as a directive and are frustrated that their expertise is not respected

Feedback and proposed changes are resisted or not engaged with because clinicians feel like measures do not adequately capture their work

Audit and feedback delivered to medics by non-medical professional (e.g. community nurse, project officer)