Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy.

Abstract

Background Audit and feedback (A&F) interventions improve patient care but may result in negative effects. To evaluate plausible harms and maximise benefits, a-priori theorisation using dark logic models can be useful. We aimed to assess the unintended adverse effects of A&F in colonoscopy using Feedback Intervention Theory (FIT) based dark logic model. Methods As part of the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial we undertook a qualitative study exploring current A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six NHS endoscopy centres across England, purposively sampled for clinical background and professional experience. A framework method analysis of A&F in endoscopy was performed, mapping themes of paradoxical outcomes and patient harm to FIT and the theory of planned behaviour (TPB). Results Data saturation was achieved on 19th participant, with endoscopists from nursing, surgical and medical professional backgrounds and a median of 7 years’ endoscopy experience (range 2–29 years).

How do healthcare providers use national audit data for improvement?

“…(17,18,45,46) This can be attributed to different factors, including the heterogeneity and complexity of provider behaviour change interventions and the poor reporting of interventions in primary studies (17,30) compounded by the limited use of theory in the design, implementation, evaluation and reporting of A&F interventions. (3,30,(47)(48)(49)(50)(51) Given that signi cant resources, including clinicians time are increasingly invested in NCAs, greater research effort needs to be devoted to understand and improve the consistency and magnitude of the NCAs' effects. (2,6,14,17,21,26,29) This research should identify underlying mechanisms through which feedback is effective and understand ingredients required to produce the most desirable effects of A&F as a QI tool.…”

Channelling the force of audit and feedback: averting the dark side

“…Catlow et al 3 in this edition of the journal investigated the unintended consequences of audit and feedback using an innovative approach. They undertook a theory-informed qualitative study of 19 endoscopists from six English National Health Service (NHS) endoscopy centres.…”

Preparing for audit and feedback: practical considerations

“…Fourth, watch out for the unintended consequences of A&F where there could be an impact on health professionals’ anxiety, morale, team dynamics, professional culture, and staff retention along with resource utilization and costs and to the wider patient community 7 …”