Disparities in patient care and outcomes provide significant issues for healthcare systems. Reviewing clinical performance against defined standards and directing action towards areas not reaching these standards is the goal of audit and feedback, both of which are designed to enhance patient care.
The term “revenue cycle” is often used to describe the beginning of a patient account’s establishment process all the way through to the end when payment is received. It is a cornerstone of quality improvement and is utilized many national clinical audit initiatives. The irony is that there is a chasm between the potential of audit and feedback and the results that they actually provide, regardless of the level of leadership.
Progress is slower than planned for other areas of treatment, despite the fact that certain national audits have been successful in promoting better and eliminating variations in care, such as for stroke and lung cancer. The history of audits and criticism is not a smooth one.
Top-down feedback can make clinicians feel threatened rather than supported, and they are justified in wondering if the benefits are worth the time and energy required to complete a poorly designed audit. Organizations in the healthcare sector often lack the means to properly support and respond to audits and feedback. However, incorporating effective strategies for enhancing patient outcomes can shift the focus towards constructive improvement rather than criticism.
Ineffective feedback replies are hampered by dysfunctional relationships between clinicians and managers, and this is especially true when feedback is not clearly part of an integrated approach to quality assurance and improvement. Unsurprisingly, audit and feedback have not reached their full potential. Here’s how you can reach them:
1. Reconsider the entire process
Determining best practice criteria, evaluating current practice, sending back findings, implementing changes, and continuing monitoring are all steps in the audit and feedback process.
As with any chain, this one is only as sturdy as its weakest link. Weakened feedback effects can result from information-intention gaps (when feedback fails to convince receivers that change is important), intention-behavior gaps (when feedback fails to translate intentions into action), or behavior-impact gaps (when feedback fails to have the desired effect).
A nation’s audit program can only succeed with supportive local arrangements that encourage action in addition to measurement. National audit programs can become meaningless echo chambers of good intentions and blame for lack of success when local networks and systems are dysfunctional.
If local quality development relies on recurrent, disconnected, and inadequately delegated projects carried out in isolation from mainstream interests, and if any knowledge is dissipated in collective amnesia, then audit and feedback will fail.
Leaders in the clinical and management spheres should seek feedback on the organization’s performance and use that information to inform goal-setting, resource allocation, and the pursuit of continuous improvement. While audit and feedback alone won’t fix systemic problems, they can highlight change objectives, guide targeted efforts, and assess outcomes.
2. Optimize the use of limited information
It is difficult for healthcare organizations and physicians to implement all of the recommendations made by national and local audit programs due to the many competing demands on their time. In 2012, a snapshot was taken showing that 107 clinical guidelines from the National Institute for Health and Care Excellence were applicable to primary care, yielding a total of 2,365 recommendations. Audit programs can assist find out which suggestions will aid patients and populations the most.
Time spent on data collection, especially the human evaluation of patient records, is a major expense of audit programs. The urge to acquire even more data in order to run studies that yield just little gains in precision might make an already difficult task even more onerous. The ensuing feedback has the potential to increase trust in the data and give users new ways to discover hidden connections.
However, there is a risk of cognitive overload and distraction from vital information if bigger amounts of complicated data are provided. The cost of putting in extra effort to improve data quality is increasing while the benefits remain constant.
Opportunities for large-scale, efficient feedback programs arise with the increasing availability of electronic patient record systems and frequently collected data on the quality of care. Manual reviews pose the hazards of biased sampling due to factors such as the loss of patient records for those with lower outcomes, but these methods cover a larger population.
Coding at the point of care is the single most important factor in ensuring high-quality data. The workload of clinical teams may increase if they are also responsible for doing validity checks and quality control of the data. Information governance and data protection laws must be followed in order to safely link and extract data from several sources.
3. Utilize public and patient participation
Researchers and healthcare professionals have much to gain by expanding their understanding of the best ways to collaborate with patients and the public through audit programs. This calls for a shift away from the status quo of engagement, which often consists of jobs in advisory groups meant to ensure responsibility and contribute to strategy.
Audit programs’ primary function is to inform patients and the public about the scope of unnecessary variances in healthcare delivery. They lament the challenges of frequently gauging soft skills like consultation and patient-centeredness. It is crucial to include patients and the public, including underrepresented groups, in the early stages of indicator development.
Hence, patients and the general public are an untapped and underutilized resource that audit programs can learn to tap into.
4. Deliver accurate information to the appropriate recipients
Comparative performance feedback across healthcare providers and facilities can tap into natural competitive drives. This may not always have the desired effect. One of life’s greatest frustrations is being told over and over that one has made a mistake.
Nonetheless, this is typically the case when doctors and organizations receive criticism indicating subpar performance. Feedback is more likely to lead to growth in areas where performance was low, to begin with, but it can also provoke defensive reactions if the recipient believes the feedback is inaccurate.
Given that doctors have a habit of exaggerating their abilities, this sort of reaction is not surprising. Constant criticism that is taken as punishment can also be discouraging and lead to burnout.
Professionals that take pleasure in their job appreciate thoughtful criticism. Take the case of delivering feedback to strong performers; does favorable feedback cause complacency or drive them to work harder? Should audit programs, at the risk of tiring out its best performers, shift focus to other areas where performance is weaker?
Efforts to boost performance that is already high may not yield as many benefits as shifting focus to a different area. Because hospitals and doctors’ offices are often already operating at or near their full capacity, there is a “ceiling” above which further progress is unlikely in many therapeutic activities.
Conclusion
In healthcare, audit and feedback are frequently employed, occasionally misused, and frequently underutilized. Conversations between physicians, patient care, and academic communities that are informed by evidence are necessary for the development of more creative designs and answers. We must now maximize the use of national audits to speed up data-guided improvement and lessen unjustified variations in healthcare.
