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      Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research


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          Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients (“feedback”) is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory.


          We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions.


          We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback’s success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective.


          This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments.

          Trial registration

          PROSPERO, CRD42015017541

          Electronic supplementary material

          The online version of this article (10.1186/s13012-019-0883-5) contains supplementary material, which is available to authorized users.

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          Most cited references 88

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          Appraising the quality of qualitative research.

          In the process of undertaking a meta-synthesis of qualitative studies of free-standing midwife-led units, the authors of this paper encountered a number of methodologically and epistemologically unresolved issues. One of these related to the assessment of the quality of qualitative research. In an iterative approach to scoping this issue, we identified eight existing checklists and summary frameworks. Some of these publications were opinion based, and some involved a synthesis of pre-existing frameworks. None of them provide a clear map of the criteria used in all their reviewed papers, and of the commonalities and differences between them. We critically review these frameworks and conclude that, although they are epistemologically and theoretically dense, they are excessively detailed for most uses. In order to reach a workable solution to the problem of the quality assessment of qualitative research, the findings from these frameworks and checklists were mapped together. Using a technique we have termed a 'redundancy approach' to eliminate non-essential criteria, we developed our own summary framework. The final synthesis was achieved through reflexive debate and discussion. Aspects of this discussion are detailed here. The synthesis is clearly rooted in a subjectivist epistemology, which views knowledge as constructed and hermeneutic in intent, encompassing individual, cultural and structural representations of reality.
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            The experiences of professionals with using information from patient-reported outcome measures to improve the quality of healthcare: a systematic review of qualitative research.

            To synthesise qualitative studies that investigated the experiences of healthcare professionals with using information from patient-reported outcome measures (PROMs) to improve the quality of care. A qualitative systematic review was conducted by searching PubMed, PsycINFO and CINAHL with no time restrictions. Hand searching was also performed. Eligible studies were evaluated using the Critical Appraisal Skills Programme toolkit for qualitative studies. A thematic synthesis identified common themes across studies. Study characteristics were examined to explain differences in findings. All healthcare settings. Healthcare professionals. Professionals' views of PROMs after receiving PROMs feedback about individual patients or groups of patients. Sixteen studies met the inclusion criteria. Barriers and facilitators to the use of PROMs emerged within four main themes: collecting and incorporating the data (practical), valuing the data (attitudinal), making sense of the data (methodological) and using the data to make changes to patient care (impact). Professionals value PROMs when they are useful for the clinical decision-making process. Practical barriers to the routine use of PROMs are prominent when the correct infrastructure is not in place before commencing data collection and when their use is disruptive to normal work routines. Technology can play a greater role in processing the information in the most efficient manner. Improvements to the interpretability of PROMs should increase their use. Attitudes to the use of PROMs may be improved by engaging professionals in the planning stage of the intervention and by ensuring a high level of transparency around the rationale for data collection. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
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              Meta-analysis: audit and feedback features impact effectiveness on care quality.

              Audit and feedback (A&F) has long been used to improve quality of care, albeit with variable results. This meta-analytic study tested whether Feedback Intervention Theory, a framework from industrial/organizational psychology, explains the observed variability in health care A&F research. studies cited by Jamtvedt's 2006 Cochrane systematic review of A&F, followed by database searches using the Cochrane review's search strategy to identify more recent studies. Cochrane review criteria, plus: presence of a treatment group receiving only A & F; a control group receiving no intervention; a quantitatively measurable outcome; minimum n of 10 per arm; sufficient statistics for effect size calculations. Moderators: presence of discouragement and praise; correct solution, attainment level, velocity, frequency, and normative information; feedback format (verbal, textual, graphic, public, computerized, group vs. individual); goal setting activity. meta-analytic procedures using the Hedges-Olkin method. Of 519 studies initially identified, 19 met all inclusion criteria. Studies were most often excluded due to the lack of a feedback-only arm. A&F has a modest, though significant positive effect on quality outcomes (d = 0.40, 95% confidence interval = +/-0.20); providing specific suggestions for improvement, written, and more frequent feedback strengthened this effect, whereas graphical and verbal feedback attenuated this effect. A&F effectiveness is improved when feedback is delivered with specific suggestions for improvement, in writing, and frequently. Other feedback characteristics could also potentially improve effectiveness; however, research with stricter experimental controls is needed to identify the specific feedback characteristics that maximize its effectiveness.

                Author and article information

                Implement Sci
                Implement Sci
                Implementation Science : IS
                BioMed Central (London )
                26 April 2019
                26 April 2019
                : 14
                [1 ]ISNI 0000000121662407, GRID grid.5379.8, Centre for Health Informatics, , University of Manchester, ; Manchester, UK
                [2 ]ISNI 0000000121662407, GRID grid.5379.8, Centre for Primary Care, , University of Manchester, ; Manchester, UK
                [3 ]ISNI 0000000084992262, GRID grid.7177.6, Department of Medical Informatics, , Amsterdam University Medical Centres, ; Amsterdam, The Netherlands
                [4 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Department of Family and Community Medicine, , University of Toronto, ; Toronto, Canada
                [5 ]ISNI 0000 0004 1936 8497, GRID grid.28577.3f, Centre for Health Services Research, , City University of London, ; London, UK
                [6 ]ISNI 0000 0000 9606 5108, GRID grid.412687.e, Centre for Implementation Research, , Ottawa Hospital Research Institute, ; Ottawa, Canada
                [7 ]ISNI 0000000121901201, GRID grid.83440.3b, Centre for Behaviour Change, , University College London, ; London, UK
                [8 ]ISNI 0000 0001 2182 2255, GRID grid.28046.38, School of Epidemiology & Public Health, , University of Ottawa, ; Ottawa, Canada
                [9 ]ISNI 0000 0001 2182 2255, GRID grid.28046.38, School of Psychology, , University of Ottawa, ; Ottawa, Canada
                © The Author(s). 2019

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funded by: Wellcome Trust (GB)
                Award ID: 104438/Z/14/Z
                Award Recipient :
                Systematic Review
                Custom metadata
                © The Author(s) 2019


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