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Abstract
Background Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.
Methods We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.
Results Data saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years’ experience.
When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages’ motives and consider gaming.
Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient.
Conclusion Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.
Trial registration number ISRCTN11126923.
- audit and feedback
- healthcare quality improvement
- qualitative research
Data availability statement
Data are available upon reasonable request. All participants provided written consent for non-identifiable publication of transcript extracts and direct quotations from data. Data were accessed in conjunction with Newcastle University data security policy. The data sets generated and/or analysed during the current study are not publicly available due to possible identification of participants through triangulation but are available from the corresponding author upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Data availability statement
Data are available upon reasonable request. All participants provided written consent for non-identifiable publication of transcript extracts and direct quotations from data. Data were accessed in conjunction with Newcastle University data security policy. The data sets generated and/or analysed during the current study are not publicly available due to possible identification of participants through triangulation but are available from the corresponding author upon reasonable request.
Supplementary materials
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Footnotes
Twitter @DrJamieC, @RashmiBhardwaj0
Contributors JC acted as guarantor, developed the qualitative methodology, interviewed participants, analysed and interpreted data and wrote the manuscript. RB-G and LS were major contributors to the qualitative methodology, checked transcripts and codes and were major contributors in writing the manuscript. MDR developed the NED-APRIQOT protocol, identified eligible NHS endoscopy centres and was a contributor in writing the manuscript. FFS was a major contributor to both the qualitative methodology and in writing the manuscript.
Funding This study was funded by the Health Foundation (695428).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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