Audit and feedback (A&F) aims to monitor and drive improvements in healthcare delivery and patient outcomes. A recipient, at individual-, team-, or unit-level, is provided with summary data of their performance over a specified period of time (frequently with a peer or benchmark comparator) to stimulate quality improvement. A&F generally leads to some improvements in professional practice.1 The feedback cycle by Brown et al. draws attention to aspects of the feedback cycle to optimize the impact of audit and feedback.2 However, the effectiveness of audit and feedback depends on several factors that are worth considering. This editorial puts forward practical considerations that should go into the pre-planning project to strengthen A&F programs.

First, ask the right question as prioritized by the healthcare system partner to ensure that the topic is one that truly needs addressing.3 The questions should aim to match the goals, timeline, or budget of the host organization. Several questions have been identified to help with setting the appropriate parameters to operationalizing A&F in a healthcare service setting. For example, does A&F work for this condition and setting? Does it work equally across all dimensions of care? How should it be prepared? How intensive should feedback be? How should it be delivered? What activities, if any, should accompany feedback? What should be done about the poorest performers detected by the audit?4,5

Second, use the substantial evidence base on how to optimize A&F interventions.1,6 People use audit and feedback without understanding how and when it works best. Using the available research evidence can help in defining the problem better and in optimizing effectiveness of the A&F interventions. Also, consider using the evidence base to inform decisions about other potentially effective implementation strategies that should be considered and vary considerably in their resource requirements and cost effectiveness.

Third, ensure a robust data system for timeliness and validity of data and an appropriate comparator (peer group, benchmark etc.). The commonest criticisms of A&F by clinicians are that ‘the data are wrong’ (e.g., diagnostic tests have been inappropriately attributed) or that ‘my patients are different’ (e.g., comparator data are inappropriate). This is why it is important that data collection and analysis produce a true representation of clinical performance.5

Fourth, watch out for the unintended consequences of A&F where there could be an impact on health professionals’ anxiety, morale, team dynamics, professional culture, and staff retention along with resource utilization and costs and to the wider patient community.7

There is no one-size-fits-all approach to delivering feedback effectively, but we can accelerate the understanding and effectiveness of interventions if we capture the lessons learned from previous projects and incorporate them systematically into future projects. To increase the effect of A&F, it is important to pay careful attention to the above practical considerations and to weigh the potential benefit against the potential challenges with respect to cost and logistics.

Acknowledgements Conflicts of interest

We, the named authors confirm this is original work that has not been submitted in part, or in full elsewhere.

REFERENCES 1. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; CD000259. 2. Brown B, Gude WT, Blakeman T, et al. 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. Implement Sci 2019; 14:1–25. 3. Grimshaw J, Ivers N, Linklater S, et al. Reinvigorating stagnant science: implementation laboratories and a meta-laboratory to efficiently advance the science of audit and feedback. BMJ Qual Saf 2019; 28:416–423. 4. Foy R, Eccles M, Jamtvedt G, et al. What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review. BMC Health Serv Res 2005; 5:1–7. 5. Foy R, Thomas A, Willis SLA, Khan T, Brown B. A brief guide to effective audit and feedback. University of Leeds; 2022. 6. Brehaut JC, Colquhoun HL, Eva KW, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med 2016; 164:435–441. 7. Catlow J, Bhardwaj-Gosling R, Sharp L, et al. Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy. BMJ Qual Saf 2021; [Epub ahead of print].