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. 2019 Apr 26;14(1):40.
doi: 10.1186/s13012-019-0883-5.

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

Benjamin Brown  1   2 , Wouter T Gude  3 , Thomas Blakeman  4 , Sabine N van der Veer  5 , Noah Ivers  6 , Jill J Francis  7   8 , Fabiana Lorencatto  9 , Justin Presseau  8   10   11 , Niels Peek  5 , Gavin Daker-White  4
Affiliations

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

Benjamin Brown et al. Implement Sci. .

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: Clinical audit; Feedback; Learning health system; Performance measurement; Qualitative evidence synthesis; Qualitative research; Quality improvement; Theory.

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Conflict of interest statement

Authors’ information

BB, TB and NI are academic primary care physicians. They have extensive experience as recipients, practitioners, and researchers of feedback. BB is expert in informatics-based feedback interventions. TB is expert in qualitative research methods. NI led the latest Cochrane review on feedback, and is internationally recognised as a leading authority on feedback interventions.

WG is a PhD candidate in Health Informatics, whose thesis focuses on evaluating feedback interventions.

SNV and NP are Health Informatics researchers. They have conducted influential systematic reviews on feedback interventions, and have extensive experience as practitioners and researchers of feedback – particularly in the fields of cardiac rehabilitation and intensive care. Their work has led to the national adoption of feedback interventions across The Netherlands.

JJ, FL and JP are academic psychologists and experts in behaviour change theory. They have extensive experience as practitioners and researchers of feedback. They have been involved in national trials in the UK aiming to optimise feedback regarding blood transfusions in hospital.

GDW is an experienced qualitative researcher and expert in its meta-synthesis. He has written influential guidance on meta-synthesis methods.

BB, NI, WG, NP, JJ, FL, and JP are founding members of the A&F MetaLab (www.ohri.ca/auditfeedback/): an international network of researchers promoting and facilitating the advancement of feedback research.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

JP is an Associate Editor for Implementation Science but was not involved in any editorial decisions for this manuscript. The other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Data synthesis process
Fig. 2
Fig. 2
Flowchart of study screening process
Fig. 3
Fig. 3
Clinical Performance Feedback Intervention Theory’s variables and explanatory mechanisms, and their influence on the feedback cycle. Solid arrows are necessary pathways for successful feedback. Dotted arrows represent potential pathways
See this image and copyright information in PMC

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