Authors

1. McReynolds, Patricia GCertBiometrics, BHltSc (Nursing)

Abstract

Review question/objective: The objective of this systematic review is to synthesize the best available evidence for the effectiveness of audit and feedback as a quality improvement strategy. More specifically, the objectives are to identify:

1. What characteristics contribute to an effective audit and feedback cycle in aged care.

2. Whether audit and feedback is an effective quality improvement strategy for improving health outcomes for older people in residential aged care facilities.

3. What the most effective feedback mechanisms as part of an audit and feedback cycle in implementing practice change are.

Background: Systematic reviews of the effectiveness of audit and feedback as a quality improvement strategy to improve practice and health care outcomes have been reported since 2000 with varying effects being identified.1 Traditionally, these reviews have examined medical practices and the acute health care sector. The most recent systematic review - conducted in 2012 - on audit and feedback outlined that this process has been widely used as a quality improvement tool and concluded that the implication for practice "generally leads to small but potentially important improvements in professional practice".2^(p.2) It also concluded that "the effectiveness of feedback seems to depend on baseline performance and how feedback is provided".2^(p.2) This review only included randomized controlled trials, the participants were healthcare professionals including physicians, pharmacists and nurses responsible for patient care and it included both inpatient and outpatient settings.2

Audit and feedback and clinical audit appear to be used interchangeably in the literature. In the United Kingdom a clinical audit was seen as one approach to improving the quality of patient care and was introduce in the 1990s. One article defined clinical audit as: 'the systematic, critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient' or "audit is the process of reviewing the delivery of care to identify deficiencies so that they may be remedied".1^(p.24)

PubMed defines clinical audit as 'a detailed review and evaluation of selected clinical records by qualified professional personnel to improve the quality of patient care and outcome'. Interestingly there was no definition on PubMed for audit and feedback. Audit and feedback was defined in a systematic review in 2006 as "the provision of any summary of clinical performance over a specified period of time".3

However, Pearson et al. 2007 provide a clearer description of clinical audit describing it as a tool that addresses all components of clinical effectiveness where health professionals examine their care practices against clinical guidelines or best practice statements. Pearson et al also explain that clinical effectiveness includes "best-practice activities such as systematic reviews, clinical guidelines and clinical audit".4^(p.134) The authors describe the clinical audit and feedback process as a method of promoting evidence utilization and how it can be utilized an "internal mechanism for health professionals to use for quality improvement".4^(p.138)

However, an initial search of various databases indicated that the term clinical audit is not commonly used in studies involving residential aged care facilities and more often the term audit and feedback is used. Therefore this review will include both audit and feedback, and clinical audit, in its search strategy focusing on implementation of evidence-based practice.

A literature review conducted in 2009, identified eight factors that might influence the implementation (utilization) of evidence-based practice in aged care in Australia.5 These included:

* "a receptive context for change;

* having a model of change to guide implementation;

* adequate resources;

* staff with the necessary skills;

* stakeholder engagement, participation and commitment;

* the nature of the change in practice;

* systems in place to support the use of evidence; and

* demonstrable benefits of the change".5

Whilst this review did not specifically look at audit and feedback the underlying assumption was that 'evidence-based practice is about taking something new (the evidence) from one domain (research) and implementing it in another domain (practice), which describes a process used in clinical audit.5 Ives et al also stated: "in an audit and feedback process, an individual's professional practice or performance is measured and then compared to professional standards or targets".2^(p.2)

There is evidence to confirm that audit and feedback on its own or as part of a multifaceted change process can have some effect on health outcomes and practice change.1 Implementation and utilization of evidence-based practice is a challenge for researchers, educators, policy makers and health practitioners. A review that can provide evidence that the audit and feedback cycle, when used as a quality improvement strategy, can impact on clinical outcomes for a high risk population with co-morbidities, is warranted.

This is supported by Masso's literature review that outlines the Encouraging Best Practice in Residential Aged Care (EBPRAC) program, funded by the Australian Government, which was introduced in 2007 to implement evidence-based practice in residential aged care facilities.5 The program involved 13 projects working with facilities in 108 locations across six states.5 The impact of this project is outlined in the Encouraging Best Practice in Residential Aged Care Program: Final Evaluation Report (2011) which states "collectively, the projects had a positive impact on residents, staff and facilities, with considerable variation between individual projects, and within each project".6^(p.97) Changes to the care received by residents were diverse. Many of the changes built on work that had been done previously in participating facilities and were relatively small scale and incremental in nature. In part this reflects the focus of the program and the available evidence. It is also indicative of the capacity of the sector to change; however this is dependent on the availability of resources, including the knowledge and skills of staff, the nature of daily work and the influence that a wide range of factors that are largely outside the control of those trying to bring about change can have e.g. turnover of facility managers which had a significant impact on some facilities and some projects.6 This report and the literature review by Masso et al. both confirm that aged care as a profession is willing to change depending on a number of variables as outlined in both papers.5,6 A total of $12,918,238 in Commonwealth funding was allocated to round one and two of this project.6

In 2010, EBPRAC was expanded to include community aged care that consequently resulted in the name being change to: 'Encouraging Better Practice in Aged Care' (EBPAC) program. In the 2011-2012 Australian federal budget, the EBPAC initiative was incorporated into the Aged Care Services Improvement and Healthy Ageing Grants Fund. This confirms that implementing better practice in aged care is still on the political agenda and funding is being made available.

The Aged Care Standards and Accreditation Agency (previously the auditing body for aged care in Australia) has facilitated the "Better Practice" in aged care award annually. The criteria for an award were as follows:

* Is the program based on the findings of research/feedback?

* Has the program's effectiveness been measured and monitored?

* Is the program focused on achieving better outcomes for the residents?

* Does the program demonstrate evolving and improving, finding the best way of doing things?

* How does it link with the residential aged care home's continuous improvement system?

This demonstrates that implementing better practice is being supported by funding and auditing bodies nationally in Australia. A systematic review of audit and feedback as an evidence-based quality improvement strategy is essential to provide the aged care industry (including policy makers, educators, medical professionals, allied health and nursing professionals, care staff, residents, families and consumers) with a review of the effectiveness of this process in improving health outcomes and the implementation of evidence-based practice. A study using a cross-sectional post feedback survey, conducted in Canada and published in 2013, examined unregulated care provider's perceptions of audit and feedback reports.7 This report concluded that "unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care".7^(p.1) This report recommended "further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings".7^(p.1)

A search of the Cochrane Library identified 36 systematic reviews on audit and feedback and confirmed that only one of these related to aged care and had reviewed the prevention of the transmission of meticillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people.8 This search also identified 63 systematic reviews on clinical audit and there were no systematic reviews relevant to residential aged care. A search of the Joanna Briggs Institute Database of Systematic Reviews and Implementation Studies also revealed no systematic reviews or protocols had been conducted on this topic. The most recent systematic review in the Cochrane Library by Ives et al confirms that audit and feedback is effective, however it will "continue to be unreliable approach to quality improvement until we learn how and when it works best".2^(p.5) The lack of literature on audit and feedback and/or clinical audit in aged care suggests that the healthcare sector needs more information on how useful this tool could be as a quality improvement strategy to improve outcomes for residents in their care. Notwithstanding this, there are studies that have used audit and feedback as a change process in aged care some of which are randomized controlled trials. A review of these studies may provide the necessary evidence to increase the uptake of audit and feedback as a quality improvement strategy that may support the implementation and utilization of evidence-based practice.

This is a quantitative systematic review as it seeks to establish the effectiveness of audit and feedback as a quality improvement strategy. While it is acknowledged that qualitative data may inform this review, it is not within the proposed scope of this review.

Whilst this protocol has predominately reflected on the Australian aged care sector, to obtain enough studies to be included in this review, evidence will be sought globally. It is hope that the lessons learnt internationally will be transferable to the local context as the review is focusing on evidence-based practice and not local legislative requirements.