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Using audit and feedback to health professionals to ...

POLICY SUMMARY 3 Using auditand feedback tohealth professionalsto improve thequality and safetyof health careSigne Agnes Flottorp, Gro Jamtvedt,Bernhard Gibis, Martin McKeeUsing audit and feedbackto health professionalsto improve the qualityand safety of health careSigne Agnes Flottorp, Gro Jamtvedt, Bernhard Gibis, Martin McKeePolicy summary prepared for the Belgian EU Presidency Conferenceon Investing in Europe's health workforce of tomorrow: scope forinnovation and collaboration (La Hulpe, 9 10 September 2010) World health Organization 2010 and World health Organization, on behalfof the European Observatory on health Systems and Policies 2010 Address requests about publications of the WHO Regional Office for Europe to:PublicationsWHO Regional Office for EuropeScherfigsvej 8DK-2100 Copenhagen , DenmarkAlternatively, complete an online request form for documentation, healthinformation, or for permission to quote or translate, on the Regional Office website ( ).

Using audit and feedback to health professionals to improve the quality and safety of health care Signe Agnes Flottorp, Gro Jamtvedt, Bernhard Gibis, Martin McKee

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1 POLICY SUMMARY 3 Using auditand feedback tohealth professionalsto improve thequality and safetyof health careSigne Agnes Flottorp, Gro Jamtvedt,Bernhard Gibis, Martin McKeeUsing audit and feedbackto health professionalsto improve the qualityand safety of health careSigne Agnes Flottorp, Gro Jamtvedt, Bernhard Gibis, Martin McKeePolicy summary prepared for the Belgian EU Presidency Conferenceon Investing in Europe's health workforce of tomorrow: scope forinnovation and collaboration (La Hulpe, 9 10 September 2010) World health Organization 2010 and World health Organization, on behalfof the European Observatory on health Systems and Policies 2010 Address requests about publications of the WHO Regional Office for Europe to:PublicationsWHO Regional Office for EuropeScherfigsvej 8DK-2100 Copenhagen , DenmarkAlternatively, complete an online request form for documentation, healthinformation, or for permission to quote or translate, on the Regional Office website ( ).

2 All rights reserved. The Regional Office for Europe of the World HealthOrganization welcomes requests for permission to reproduce or translate itspublications, in part or in designations employed and the presentation of the material in thispublication do not imply the expression of any opinion whatsoever on the partof the World health Organization concerning the legal status of any country,territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. Dotted lines on maps represent approximate borderlines for which there may not yet be full mention of specific companies or of certain manufacturers productsdoes not imply that they are endorsed or recommended by the World HealthOrganization in preference to others of a similar nature that are not and omissions excepted, the names of proprietary products aredistinguished by initial capital reasonable precautions have been taken by the World health Organizationto verify the information contained in this publication.

3 However, the publishedmaterial is being distributed without warranty of any kind, either express orimplied. The responsibility for the interpretation and use of the material lieswith the reader. In no event shall the World health Organization be liable fordamages arising from its use. The views expressed by authors, editors, or expertgroups do not necessarily represent the decisions or the stated policy of theWorld health :PATIENT care standardsQUALITY ASSURANCE, health care standardsSAFETY MANAGEMENTHEALTH PERSONNELFEEDBACKMEDICAL AUDITOUTCOME ASSESSMENT ( health care )ISSN 2077-1584 Using audit and feedback to health professionalsto improve the quality and safety of health careContentsPageKey messagesivExecutive summary v1 Introduction12 audit and feedback as part of a strategy for improvingperformance and supporting quality and safety inEuropean health care systems23 What do we know about the effects of the different ways in which audit and feedback are used?

4 114 How to decide if and how audit and feedback should be implemented235 Closing observations27 References28 Annexes33 AuthorsSigne Agnes Flottorp, Norwegian Knowledge Centre for theHealth Services, Oslo, Norway and Department of Public Healthand Primary health care , University of Bergen, Bergen, NorwayGro Jamtvedt, Norwegian Knowledge Centre for the HealthServices, Oslo, Norway and Centre for Evidence Based Practice,Bergen University College, Bergen, NorwayBernhard Gibis, Director, Department for service contracts andpharmaceuticals, National Association of Statutory HealthInsurance Physicians, Berlin, GermanyMartin McKee, London School of Hygiene & Tropical Medicine,London, United Kingdom and European Observatory on HealthSystems and PoliciesKey messages There is now extensive evidence demonstrating that there is a gapbetween the health care that patients receive and the practice that isrecommended.

5 In both primary and secondary care there are unwarrantedvariations in practice and in resulting outcomes that cannot be explainedby the characteristics of patients. While it is difficult to find examples of measures for addressing this issuefrom all 53 countries of the World health Organization s European Region,there are interventions that can be identified in the 27 Member States ofthe European Union. However, the nature of these measures and theextent to which they are implemented vary considerably. audit and feedback defined as any summary of clinical performance ofhealth care over a specified period of time aimed at providing informationto health professionals to allow them to assess and adjust their performance is an overarching term used to describe some of the measures that areused to improve professional practice. audit and feedback can be used in all health care settings, involvingall health professionals , either as individual professions or in multi-professional teams.

6 In practical terms, health professionals can receive feedback on theirperformance based on data derived from their routine practice. Healthprofessionals involved in audit and feedback may work either in a teamor individually and in primary, secondary or tertiary care . While it seems intuitive that health care professionals would be promptedto modify their clinical practice if receiving feedback that it was inconsistentwith that of their peers or accepted guidelines, this is in fact not alwaysthe case. The available evidence suggests that audit and feedback may be effectivein improving professional practice but that the effects are generally smallto moderate. Nonetheless, depending on the context, such small effects,particularly if shown to be cost-effective, may still be regarded as worthwhile. The benefits of audit and feedback measures are most likely to occurwhere existing practice is furthest away from what is desired, and whenfeedback is more intensive.

7 Even on the basis of the best evidence available, no strong recommendationscan be given regarding the best way to introduce audit and feedback intoroutine practice. However, decisions about if, and how, this approach canPolicy summaryivbe used to improve professional practice must be guided by pragmatismand the consideration of local circumstances. The following scenarios, forexample, might indicate suitability for such an approach: the known (oranticipated) level of initial adherence to guidelines or desired practice islow; it is feasible to conduct an audit and the associated costs of collectingthe data are low; routinely collected data are reliable and appropriate foruse in an audit ; and small to moderate improvements in quality wouldbe worthwhile. The cost of audit and feedback is highly variable and is determined by localconditions, including the availability of reliable routinely collected data andpersonnel costs.

8 The impact of audit and feedback , with or without additional interventions,should be monitored routinely by auditing practice after the intervention. Executive summaryAudit and feedback as part of a strategy for improving performanceand supporting quality and safety in European health care systemsThere is now extensive evidence from every country in which it has beensought that there is a gap between the health care that patients receive, andthe practice that is recommended. In both primary and secondary care thereare unwarranted variations in practice and in the resulting outcomes, andwhich cannot be explained by characteristics of the patients. While it isdifficult to ascertain the extent to which measures for tackling this exist inall 53 Member States of the World health Organization s European Region,concrete examples can be identified in each of the 27 European Union MemberStates.

9 In particular, there is growing interest in the use of audit and feedbackfor health professionals . audit and feedback can be defined as any summary of clinical performanceof health care over a specified period of time aimed at providing informationto health professionals to allow them to assess and adjust their performance .In practical terms, health professionals , working either in a team or individually,receive feedback on their performance by reflecting on data derived from theirroutine practice. audit and feedback are intended to enhance professionalperformance and thereby improve the quality of health care and patient it seems intuitive that health professionals would be prompted tomodify their clinical practice after receiving feedback showing that it wasinconsistent with that of their peers or accepted guidelines, this has not beendemonstrated consistently. Using audit and feedback to health professionals to improve the quality and safety of health carevFeedback can be delivered in different ways, categorized in terms of therecipients, formats, sources, frequency, duration and content.

10 audit andfeedback mechanisms can be used alone or linked to other interventions. Mostresearch on the effects of audit and feedback has treated them as componentsof a multifaceted intervention, often combined with educational and feedback systems have been used in many ways in European healthsystems. The spectrum covers mandatory schemes run by governmental bodiesto voluntary professional (self-regulatory) initiatives, and it can be top-down orbottom-up or a combination of both. They can be internal, used by localgroups of practitioners, or external, run by professional bodies, researchgroups or governmental do we know about the effects of the different ways in whichaudit and feedback are used?The material in this Policy Summary is largely based on a systematic reviewof the effectiveness of audit and feedback in changing clinical practice, anda review of experiences of how audit and feedback have been used in clinicalpractice.


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