Clinical Performance Feedback Intervention Theory (CP-FIT): A Meta-synthesis of Qualitative Studies

Problem

Clinical performance feedback is a widely used quality improvement technique in primary care, yet multiple Cochrane reviews show it has variable success. Theory may help explain this variation and maximise its effectiveness; however, existing theories lack detail and are not specific to health care settings. Our aim was therefore to synthesise published qualitative evaluations of clinical performance feedback interventions to inform the development of a health care-specific theory of its effects and mechanisms.

Approach

We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Included papers used qualitative methods to evaluate interventions delivering feedback to health professionals on the extent to which they provided care to populations that adhered to pre-defined clinical standards, and/or achievement of patient outcomes. Data were synthesised by coding individual studies in batches of four, and generalising across them using Framework Analysis informed by Realistic Evaluation and existing theories. An integrated theory was developed by distilling the synthesis into a core set of propositions. The synthesis and theory were tested and refined on further batches of papers. GRADE-CERQual criteria were applied to assess the confidence in our findings.

Findings

15413 papers were identified, of which 65 were included. They reported studies of 73 feedback interventions in 24 countries, covering 23 feedback topics in primary and secondary care, nursing home and mental health settings. The synthesis suggests effective clinical performance feedback is a cyclical process of Goal setting, Audit, Feedback, recipient Interaction, Perception, and Acceptance of the feedback, followed by Intention and Behaviour. Progress round this cycle is influenced by intervention and context predictor variables relating to characteristics of the Goal, Audit methods, Feedback message, Implementation process, Organisational context, Co-interventions, Health professional, and Patient population. These variables exert their effects via mechanisms relating to Actionability, Resource match, Complexity, Relative advantage, Compatibility, Credibility, and Social influence. Unintended outcomes of clinical performance feedback include Gaming and Tunnel vision. Based on these findings, we developed Clinical Performance Feedback Intervention Theory (CP-FIT), whose three propositions state that: 1) Clinical performance feedback exerts its effects by influencing patient-level behaviours in health professionals by facilitating Direct Action and/or raising Knowledge/Awareness; 2) Health care organisations have limited capacity to engage with and respond to clinical performance feedback; and 3) Health care professionals and organisations have a strong set of beliefs and behaviours regarding patient care that influence their interactions with clinical performance feedback.

Consequences

CP-FIT is a detailed and comprehensive new theory of causal pathways in clinical performance feedback designed specifically for health care. Its predictor variables and propositions provide tentative explanations for the observed variation reported in Cochrane reviews. Future research should empirically test and refine CP-FIT’s ability to inform the design, implementation, and evaluation of clinical performance feedback interventions.