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Table 8 Example quotes from included papers

From: Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research

Number Quote CP-FIT constructs illustrated
1 Physicians’ disagreement with the assessment process results in no action. When they feel performance is based on a small sample of patients that is not representative of the care they provide they ignore the feedback and do not take any action … “The N is incredibly tiny. These patients may not be representative of our typical patient, yet these numbers are taken very seriously.” (Author interpretation and participant quote of a feedback intervention in US primary care [50]) Feedback cycle processes: Acceptance, Behaviour
Variables: Data collection and analysis method
Mechanisms: Credibility
2 Many participants argued that much quality assurance work is being done within the field of diabetes care. As a counterweight, many felt that conditions like hypertension and chronic obstructive pulmonary disease (COPD) were in more need of attention. (Author interpretation of a feedback intervention focusing on diabetes care in Denmark [82]) Feedback cycle processes: Tunnel vision
Variables: Importance
Mechanisms: Credibility, Compatibility
3 All GPs interviewed highly valued the process of reviewing patients identified as receiving high-risk NSAID [non-steroidal anti-inflammatory drug] or antiplatelet prescriptions. “The topic is, I would go so far as to say, essential. I do not even think you can say it’s urgent. It’s essential that practices are doing this. They could be killing patients totally unnecessarily” (Author interpretation and participant quote regarding feedback on potential medication safety errors in Scotland[94]) Feedback cycle processes: Acceptance, Intention
Variables: Importance
Mechanisms: Compatibility
4 The California physicians … [complained] strongly about the accuracy of the data on which their performance was judged... “I have 91 diabetics,” one explained, of whom 32 were reported as “missing either a haemoglobin A1C or an LDL or [to] have elevated levels from September to August ‘07.” But, when he went through the labs and charts, “just on the first two pages I found that six of them were incorrect” (Author interpretation and participant quote regarding feedback in primary care in the US [153]) Feedback cycle processes: Verification, Acceptance
Variables: Accuracy
Mechanisms: Credibility
5 The informants suggested that the identities of the inappropriately treated patients should be revealed in prescriber feedback … “It was frustrating that I had a quality problem without being able to do something about it... (but)... I am not sure whether I actually have a quality problem” (Author interpretation and participant quote regarding feedback on medication prescribing in Denmark [154]) Feedback cycle processes: Verification, Acceptance, Perception, Intention, Behaviour
Variables: Patient lists
Mechanisms: Credibility, Actionability
6 Interviewees expressed even greater scepticism about public reporting of performance data … “Sharing [performance data] with [patients] without the opportunity first to improve things might be viewed as punitive.” (Author interpretation and participant quote regarding hospital-based feedback on stroke in the US [155]) Feedback cycle processes: Acceptance
Variables: Function
Mechanisms: Compatibility
7 No participants reported using the feedback to set specific goals for improvement or action plans for reaching these goals. Even when prompted, most participants could not envision ways for the practice to facilitate pro-active chronic disease management … (Author interpretation of feedback focusing on chronic diseases in Canada [90]) Feedback cycle processes: Intention, Behaviour
Variables: Knowledge and skills in quality improvement
Mechanisms: Actionability, Resource match
8 Increased awareness of suboptimal performance usually resulted in the intention to “try harder” to do more during each patient visit, rather than “work smarter” by implementing point-of-care reminders or initiating systems to identify and contact patients for reassessment … Such findings help to explain the small to moderate effects generally observed in randomised trials of audit and feedback. (Author interpretation of feedback intervention focusing on chronic diseases in Canada [90]) Feedback cycle processes: Intention, Behaviour, Clinical performance improvement
Variables: Organisation-level behaviour, Patient-level behaviour
Mechanisms: Actionability
9 In both interviews and observed meetings, the executive team expressed a deep commitment to ensuring the safety and quality of the services provided by the hospital. Members of the team identified the [feedback system] as a major strategic component of this commitment and made an accordingly heavy investment (approximately UK£25 million or US$38 million over ten years). (Author interpretation of a hospital-based feedback intervention in England [87]) Feedback cycle processes: Nil
Variables: Leadership support, Resource
Mechanisms: Resource match, Social influence
10 That effective surgical site infection [SSI] prevention requires a team effort was a preponderant view … Interprofessional collaboration between clinicians, especially between surgeons and anesthesiologists, was invariably viewed as an integral part of the consistent application of best practices and, ultimately, the successful prevention of SSIs. (Author interpretation of a feedback intervention focusing on the reduction of surgical site infections in Canada [72]) Feedback cycle processes: Behaviour (patient-level)
Variables: Teamwork, Intra-organisational networks
Mechanisms: Actionability, Compatibility, Social influence
11 Most providers (as well as some managers) expressed helplessness in their ability to respond [to feedback], especially when large proportions of the list consisted of challenging patients that, despite best efforts, could not achieve treatment goals …. the link between results and evaluation can be undermined when criteria … do not align with treatment guidelines, the latest evidence, and especially principles of patient-centered care. (Author interpretation of feedback focusing on diabetes treatment in US primary care [58]) Feedback cycle processes: Intention, Behaviour (patient-level), Clinical performance improvement
Variables: Choice alignment, Clinical appropriateness
Mechanisms: Actionability, Compatibility, Complexity
12 An active and interactive approach was observed in teams A and B, reflected in the planning of regular team meetings for discussions of scores, possible problems and solutions, and appointing a responsible person to take action. This approach was lacking in teams C and D, as confirmed by the surgeon from team D: “We should have looked at the data more often and also discussed the results to discover weaknesses.” (Author interpretation and participant quote regarding feedback on breast cancer surgery in The Netherlands [62]) Feedback cycle processes: Interaction, Perception, Intention, Behaviour
Variables: Peer discussion, Problem solving, Action planning
Mechanisms: Actionability, Compatibility, Complexity, Social influence, Resource match
13 In Cuba and Bolivia, clinicians saw improvements as a direct result of the audit. Clinicians therefore considered audit a worthwhile activity and found it to be a key motivational factor and facilitator in improving clinical practice. (Author interpretation of feedback targeting tuberculosis diagnosis in South America [97]) Feedback cycle processes: Interaction, Intention
Variables: Observability
Mechanisms: Relative advantage