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Next-generation audit and feedback for inpatient quality improvement using electronic health record data: a cluster randomised controlled trial
  1. Sajan Patel1,
  2. Alvin Rajkomar1,
  3. James D Harrison1,
  4. Priya A Prasad1,
  5. Victoria Valencia2,
  6. Sumant R Ranji3,
  7. Michelle Mourad1
  1. 1 Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, USA
  2. 2 Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
  3. 3 Department of Medicine, Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
  1. Correspondence to Dr. Sajan Patel, Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA 94143, USA; sajan.patel{at}


Background Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting.

Methods We conducted a cluster randomised control trial comparing intensive audit and feedback with usual audit and feedback from February 2016 to June 2016. The study subjects were internal medicine teams on the teaching service at an urban tertiary care hospital. Teams in the intensive feedback arm received access to a daily-updated team-based data dashboard as well as weekly inperson review of performance data (‘STAT rounds’). The usual feedback arm received ongoing twice-monthly emails with graphical depictions of team performance on selected quality metrics. The primary outcome was performance on a composite discharge metric (Discharge Mix Index, ‘DMI’). A washout period occurred at the end of the trial (from May through June 2016) during which STAT rounds were removed from the intensive feedback arm.

Results A total of 40 medicine teams participated in the trial. During the intervention period, the primary outcome of completion of the DMI was achieved on 79.3% (426/537) of patients in the intervention group compared with 63.2% (326/516) in the control group (P<0.0001). During the washout period, there was no significant difference in performance between the intensive and usual feedback groups.

Conclusion Intensive audit and feedback using timely data and STAT rounds significantly increased performance on a composite discharge metric compared with usual feedback. With the cessation of STAT rounds, performance between the intensive and usual feedback groups did not differ significantly, highlighting the importance of feedback delivery on effecting change.

Clinical Trial The trial was registered with (NCT02593253).

  • audit and feedback
  • hospital medicine
  • performance measures
  • quality improvement
  • randomised controlled trial

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  • Contributors As the principal and corresponding author, I assert that every person who contributed to the writing of this manuscript is listed as an author, and that each person listed as an author had an active and significant impact on the conceptualisation, performance and analysis of research in this article. This work has not been previously published.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval The University of California, San Francisco Institutional Review Board (UCSF Committee on Human Research) reviewed this trial and given the quality improvement focus was classified as not human subjects research.

  • Provenance and peer review Not commissioned; externally peer reviewed.