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Use of a maternal newborn audit and feedback system in Ontario: a collective case study
  1. Jessica Reszel1,2,
  2. Sandra I Dunn1,2,3,
  3. Ann E Sprague1,2,3,
  4. Ian D Graham4,5,
  5. Jeremy M Grimshaw4,5,6,
  6. Wendy E Peterson3,
  7. Holly Ockenden1,
  8. Jodi Wilding2,
  9. Ashley Quosdorf3,
  10. Elizabeth K Darling7,
  11. Deshayne B Fell2,5,
  12. JoAnn Harrold2,4,8,9,
  13. Andrea Lanes1,5,
  14. Graeme N Smith10,
  15. Monica Taljaard4,5,
  16. Deborah Weiss1,5,
  17. Mark C Walker1,4,5,11,12,13
  1. 1 Better Outcomes Registry & Network (BORN), Children’s Hospital of Eastern Ontario — Ottawa Children’s Treatment Centre (CHEO-OCTC), Ottawa, Ontario, Canada
  2. 2 Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  3. 3 School of Nursing, University of Ottawa, Ottawa, Ontario, Canada
  4. 4 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  5. 5 School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  6. 6 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  7. 7 McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada
  8. 8 Division of Neonatology, Children's Hospital of Eastern Ontario and The Ottawa Hospital, Ottawa, Ontario, Canada
  9. 9 Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
  10. 10 Department of Obstetrics & Gynecology, Queen’s University and Kingston General Hospital, Kingston, Ontario, Canada
  11. 11 Obstetrics, Maternal and Newborn Investigations (OMNI) Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  12. 12 Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada
  13. 13 Department of Obstetrics and Gynecology, The University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Jessica Reszel, BORN Ontario, Ottawa, ON K1H 8L1, Canada; jreszel{at}


Background As part of a larger study examining the effectiveness of the Maternal Newborn Dashboard, an electronic audit and feedback system to improve maternal-newborn care practices and outcomes, the purpose of this study was to increase our understanding of factors explaining variability in performance after implementation of the Dashboard in Ontario, Canada.

Methods A collective case study. A maximum variation sampling approach was used to invite hospitals reflecting different criteria to participate in a 1-day to 2-day site visit by the research team. The visits included: (1) semistructured interviews and focus groups with healthcare providers, leaders and personnel involved in clinical change processes; (2) observations and document review. Interviews and focus groups were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code and categorise the data.

Results Between June and November 2016, we visited 14 maternal-newborn hospitals. Hospitals were grouped into four quadrants based on their key indicator performance and level of engagement with the Dashboard. Findings revealed four overarching themes that contribute to the varying success of sites in achieving practice change on the Dashboard key performance indicators, namely, interdisciplinary collaboration and accountability, application of formal change strategies, team trust and use of evidence and data, as well as alignment with organisational priorities and support.

Conclusion The diversity of facilitators and barriers across the 14 hospitals highlights the need to go beyond a ‘one size fits all’ approach when implementing audit and feedback systems. Future work to identify tools to assess barriers to practice change and to evaluate the effects of cointerventions to optimise audit and feedback systems for clinical practice change is needed.

  • maternal-newborn care
  • audit and feedback
  • case study
  • qualitative
  • knowledge translation
  • obstetrics

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  • Contributors SID and MCW are coprincipal investigators for the described study. SID, AES, IDG, JMG, WEP, EKD, DBF, JH, GNS, MT, MCW contributed to the conceptualisation and the design of the study. JR, HO, JW, AQ visited the hospital sites and collected and coded all data. JR, HO, JW, AQ, SID, IDG, WEP, DW contributed to analysing the data. JR and SID drafted the initial manuscript. All authors participated in the writing of this manuscript and reviewed and approved the final manuscript.

  • Funding This study was funded by the Canadian Institutes of Health Research (CIHR-FRN: 133576) and the Ontario Ministry of Health and Long-Term Care (MOHLTC—#06684). IDG is a recipient of a CIHR Foundation grant (FDN# 143237). JMG is a recipient of a CIHR Foundation grant (FDN# 143269). MCW is a recipient of a CIHR Foundation grant (FDN# 148438).

  • Disclaimer The funding bodies had no role in study design, data collection, analysis, interpretation of data or the decision to submit this or future manuscripts for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Children's Hospital of Eastern Ontario Research Ethics Board (#13/218X) and University of Ottawa Research Ethics Board (#A01-14-03).

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

  • Data sharing statement The data analysed during this study (ie, interview and focus group transcripts, photographs and hospital documents) are not publicly available due to them containing information that could compromise research participant privacy/consent.

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