Exploring variation in the use of feedback from national clinical audits: a realist investigation

Natasha Alvarado, Lynn McVey, Joanne Greenhalgh, Dawn Dowding, Mamas Mamas, Chris Gale, Patrick Doherty, Rebecca Randell

Research output: Contribution to journalArticlepeer-review


National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians’ time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation.

We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism=Outcome configurations.

We identified five mechanisms that explained interactions between providers and NCA feedback: reputation, professionalism, competition, incentives, and professional development. The mechanisms ‘professionalism’ and ‘incentives’ were found to underpin most routine use of feedback and were associated with quality improvement. Use of feedback in these ways was supported in services resourced to maintain local databases, where data were stored before upload to NCA suppliers, and from which staff could generate performance reports as needed. Furthermore, the data reported were trusted as a reliable measure of performance, due to the skills and experience of staff supporting audit participation. Feedback produced by NCA suppliers, which included national comparator data, was used across providers but in a more limited capacity. Challenges accessing supplier held data and concerns about its quality and
timeliness were reported to constrain its use as a tool to stimulate quality improvement.

The findings suggest that there are a number of mechanisms through which healthcare providers engage with NCA feedback, providing opportunities to stimulate quality improvement. However, most routine and proactive use of feedback was identified within services resourced to collect timely and accurate data and to generate reports from local, rather than NCA supplier, databases.
Original languageEnglish
JournalBMC Health Services Research
Publication statusAccepted/In press - 15 Aug 2020


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