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BackgroundAudit and feedback (A&F) is a frequently used intervention aiming to support implementation of research evidence into clinical practice with positive, yet variable, effects. Our understanding of effective A&F has been limited by poor reporting and intervention heterogeneity. Our objective was to describe the extent of these issues.MethodsUsing a secondary review of A&F interventions and a consensus-based process to identify modifiable A&F elements, we examined intervention descriptions in 140 trials of A&F to quantify reporting limitations and describe the interventions.ResultsWe identified 17 modifiable A&F intervention elements; 14 were examined to quantify reporting limitations and all 17 were used to describe the interventions. Clear reporting of the elements ranged from 56% to 97% with a median of 89%. There was considerable variation in A&F interventions with 51% for individual providers only, 92% targeting behaviour change and 79% targeting processes of care, 64% performed by the provider group and 81% reporting aggregate patient data.ConclusionsOur process identified 17 A&F design elements, demonstrated gaps in reporting and helped understand the degree of variation in A&F interventions.

Background While there is widespread acknowledgment of the need for improved quality and quantity of information on births and deaths, there has been less movement towards systematically capturing and reviewing the causes and avoidable factors linked to deaths, in order to affect change. This is particularly true for stillbirths and neonatal deaths which can fall between different health care providers and departments. Maternal and perinatal mortality audit applies to two of the five objectives in the Every Newborn Action Plan but data on successful approaches to overcome bottlenecks to scaling up audit are lacking. Methods We reviewed the current evidence for facility-based perinatal mortality audit with a focus on low- and middle-income countries and assessed the status of mortality audit policy and implementation. Based on challenges identified in the literature, key challenges to completing the audit cycle and affecting change were identified across the WHO health system building blocks, along with solutions, in order to inform the process of scaling up this strategy with attention to quality. Results Maternal death surveillance and review is moving rapidly with many countries enacting and implementing policies and with accountability beyond the single facility conducting the audits. While 51 priority countries report having a policy on maternal death notification in 2014, only 17 countries have a policy for reporting and reviewing stillbirths and neonatal deaths. The existing evidence demonstrates the potential for audit to improve birth outcomes, only if the audit cycle is completed. The primary challenges within the health system building blocks are in the area of leadership and health information. Examples of successful implementation exist from high income countries and select low- and middle-income countries provide valuable learning, especially on the need for leadership for effective audit systems and on the development and the use of clear guidelines and protocols in order to ensure that the audit cycle is completed. Conclusions Health workers have the power to change health care routines in daily practice, but this must be accompanied by concrete inputs at every level of the health system. The system requires data systems including consistent cause of death classification and use of best practice guidelines to monitor performance, as well as leaders to champion the process, especially to ensure a no-blame environment, and to access change agents at other levels to address larger, systemic challenges.

Background Audit and feedback (A&F) is more effective if it facilitates action planning, but little is known about how best to do this. We developed an electronic A&F intervention with an action implementation toolbox to improve pain management in intensive care units (ICUs); the toolbox contained suggested actions for improvement. A head-to-head randomised trial demonstrated that the toolbox moderately increased the intervention’s effectiveness when compared with A&F only. Objective To understand the mechanisms through which A&F with action implementation toolbox facilitates action planning by ICUs to increase A&F effectiveness. Methods We extracted all individual actions from action plans developed by ICUs that received A&F with ( n  = 10) and without ( n  = 11) toolbox for 6 months and classified them using Clinical Performance Feedback Intervention Theory. We held semi-structured interviews with participants during the trial. We compared the number and type of planned and completed actions between study groups and explored barriers and facilitators to effective action planning. Results ICUs with toolbox planned more actions directly aimed at improving practice ( p  = 0.037) and targeted a wider range of practice determinants compared to ICUs without toolbox. ICUs with toolbox also completed more actions during the study period, but not significantly ( p  = 0.142). ICUs without toolbox reported more difficulties in identifying what actions they could take. Regardless of the toolbox, all ICUs still experienced barriers relating to the feedback (low controllability, accuracy) and organisational context (competing priorities, resources, cost). Conclusions The toolbox helped health professionals to broaden their mindset about actions they could take to change clinical practice. Without the toolbox, professionals tended to focus more on feedback verification and exploring solutions without developing intentions for actual change. All feedback recipients experienced organisational barriers that inhibited eventual completion of actions. Trial registration ClinicalTrials.gov, NCT02922101 . Registered on 26 September 2016.

Background High participation and performance are necessary conditions for the effectiveness of breast cancer screening programs. Here we describe the process to define and test a planning software application and an audit cycle based on the PRECEDE-PROCEED model applied to improving breast cancer screening. We developed a planning software application following the phases of the PRECEDE-PROCEED model. The application was co-designed by local cancer screening program coordinators. An audit model was also developed. The revised application and the audit model were tested by all the coordinators of 15 breast cancer screening programs in the region of Lombardy in a 3-day workshop. The project plans produced using the application were compared with those produced in the previous year for clarity and completeness. Results The 9 phases of the PRECEDE-PROCEED model were adapted to screening as follows: 1) identification of program goals (i.e., participation, sensitivity, false positive); 2) epidemiological issues; 3) best practices analysis; 4) evidence-based actions to be implemented in the screening center and the relationships with partners and stakeholders; 5) priority setting and identification of solutions for each issue; 6) definition of indicators; 7) monitoring; 8) evaluation; 9) impact assessment. The application automatically generated reports for each phase. During the audit cycle, the regional health authority negotiated the targets to be reached with local authorities and collected the improvement plans generated by the application. The plans produced after the application was adopted were more standardized and had clearer indicators for monitoring and evaluation compared to those produced in the previous year. Conclusions The software application helps standardize criteria for planning interventions to improve screening programs and facilitates the implementation of the audit cycle.

Background National audit is a key strategy used to improve care for patients with dementia. Audit and feedback has been shown to be effective, but with variation in how much it improves care. Both evidence and theory identify active ingredients associated with effectiveness of audit and feedback. It is unclear to what extent national audit is consistent with evidence- and theory-based audit and feedback best practice. Methods We explored how the national audit of dementia is undertaken in order to identify opportunities to enhance its impact upon the improvement of care for people with dementia. We undertook a multi-method qualitative exploration of the national audit of dementia at six hospitals within four diverse English National Health Service organisations. Inductive framework analysis of 32 semi-structured interviews, documentary analysis ( n = 39) and 44 h of observations ( n = 36) was undertaken. Findings were presented iteratively to a stakeholder group until a stable description of the audit and feedback process was produced. Results Each organisation invested considerable resources in the audit. The audit results were dependent upon the interpretation by case note reviewers who extracted the data. The national report was read by a small number of people in each organisation, who translated it into an internal report and action plan. The internal report was presented at specialty- and organisation-level committees. The internal report did not include information that was important to how committee members collectively decided whether and how to improve performance. Participants reported that the national audit findings may not reach clinicians who were not part of the specialty or organisation-level committees. Conclusions There is considerable organisational commitment to the national audit of dementia. We describe potential evidence- and theory-informed enhancements to the enactment of the audit to improve the local response to performance feedback in the national audit. The enhancements relate to the content and delivery of the feedback from the national audit provider, support for the clinicians leading the organisational response to the feedback, and the feedback provided within the organisation.

While maternal and perinatal mortality auditing has been strongly promoted by the World Health Organization (WHO), there has been very limited promotion or evaluation of child death auditing in low/middle-income settings. In 2017, a standardised child death review process was introduced in the paediatric department of the National Hospital in Honiara, Solomon Islands. We evaluated the process and outcomes of child death reviews. The child death auditing process was assessed through systematic observations made at each of the weekly meetings using the following standards for evaluation: (1) adapted WHO tools for paediatric auditing; (2) the five stages of the audit cycle; (3) published principles of paediatric audit; and (4) WHO and Solomon Islands national clinical standards of Hospital Care for Children. Thirty-three child death review meetings were conducted over 6 months, reviewing 66 neonatal and child deaths. Some areas of the process were satisfactory and other areas were identified for improvement. The latter included use of a more systematic classification of causes of death, inclusion of social risk factors and community problems in the modifiable factors and more follow-up with implementation of action plans. Areas for improvement were in communication, clinical assessment and treatment, availability of laboratory tests, antenatal clinic attendance and equipment for high dependency neonatal and paediatric care. Many of the changes recommended by audit require a quality improvement team to implement. Child death auditing can be done in resource-limited settings and yield useful information of gaps which are linked to preventable deaths; however, using the data to produce meaningful changes in practice is the greatest challenge. Audit is an iterative and evolving process that needs a structure, tools, evaluation, and needs to be embedded in the culture of a hospital as part of overall quality improvement, and requires a quality improvement team to follow-up and implement action plans.

Prevention of central-line–associated bloodstream infections (CLABSIs) requires a comprehensive approach addressing the insertion, access, and maintenance of central lines.1–3 CLABSI prevention efforts are most successful when owned by local physicians and nurses, rather than seen as a problem to be solved by infection prevention or quality departments.4 Groups such as the Agency for Healthcare Research and Quality and the Joint Commission recommend unit-based audits as one tool for CLABSI prevention.5,6 At the University of North Carolina (UNC) Medical Center, a 945-bed academic hospital, our rate had stagnated at >2.00 CLABSIs per 1,000 central-line days after years of reductions. [...]infection prevention staff met with units that already had their own audit processes in place to get them using the hospital-wide tool. [...]infection prevention staff conducted individual trainings with remaining units and multiple hospital committees to ensure awareness and buy-in from stakeholders.

In this single-center study, the standardized antimicrobial administration ratio (SAAR) for total antimicrobial use decreased in response to a stewardship intervention. Antimicrobial prescribing and clinical outcomes were stable or improved during the period of lower SAARs. Our findings suggest that SAAR values of ~0.8 can be safely achieved.

The rate of unused or idle PIVCs inserted in the ED has been reported at 45%-50%.2,3 PIVC insertions in the ED have been identified as a cause for phlebitis and bacteremia, leading to their premature failure.4 Analysis of 5 years of prospective data from 2 hospitals in Australia found a high incidence of catheter-related Staphylococcus aureus bloodstream infections with 39.6% of such infections associated with PIVCs inserted in the ED.5 As a result, routine PIVC replacement should be considered after 24 hours for PIVCs inserted under emergent conditions6 and after 96 hours for those inserted under nonemergent conditions.5 These worrying statistics prompted the design of the current study that was performed to investigate how and why PIVCs are used in the ED, and during the subsequent hospital admission, as well as the documented rationale for removal of ED-inserted PIVCs by ward staff. Items included in the audit were age, gender, patient size, type of intravenous therapy given (fluids, antibiotics, and/or analgesia) or bloods taken through the cannula, Peripheral Vein Assessment Score (PVAS, the current peripheral cannula daily assessment tool at our hospital) for each day, dwell time of the PIVC, the rationale for removal (infiltration, phlebitis, occlusion, accidental removal, no longer needed, routine replacement, not documented), evidence of the type and number of other vascular access devices inserted, length of hospital stay, and whether the PIVC was used for intravenous/medication therapy in ED or in the hospital (unused/idle PIVC). The importance of good quality documentation for medical chart audits for providing confidence in results has been argued when the medical record review methodology is used.8 Our hospital uses a locally developed PVAS that isolates failure to an infection/phlebitis problem alone.

Objective Our objectives were to determine the proportion of preventable trauma deaths at a large trauma hospital in Kumasi, Ghana, and to identify opportunities for the improvement of trauma care. Methods A multidisciplinary panel of experts evaluated pre-hospital, hospital, and postmortem data of consecutive trauma patients who died over a 5-month period in 2006–2007 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For preventable and potentially preventable deaths, deficiencies in care that contributed to their deaths were identified. Results The panel reviewed 231 trauma deaths. Of these, 84 charts had sufficient information to review preventable factors. The panel determined that 23 % of trauma deaths were definitely preventable, 37 % were potentially preventable, and 40 % were not preventable. One main deficiency in care was identified for each of the 50 definitely preventable and potentially preventable deaths. The most common deficiencies were pre-hospital delays (44 % of the 50 deficiencies), delay in treatment (32 %), and inadequate fluid resuscitation (22 %). Among the 19 definitely preventable deaths, the most common cause of death was hemorrhage (47 %), and the most common deficiencies were inadequate fluid resuscitation (37 % of deficiencies in this group) and pre-hospital delay (37 %). Conclusions A high proportion of trauma fatalities might have been preventable by decreasing pre-hospital delays, adequate resuscitation in hospital, and earlier initiation of care, including definitive surgical management. The study also showed that preventable death panel reviews are a feasible and useful quality improvement method in the study setting.