1. What tasks are most amenable to effective A&F? 2. How to optimise –

a. don’t need placebo, but have standard feedback as control Individualised data, comparison data, feedback of recent

performance, include written/visual feedback b. Is audit on its own an intervention – if people are aware that their

performance is being measured without feedback? c. Are Cochrane review findings a starting point from which to generate more

effective interventions? 3. Relative effectiveness of, and interactions between, components 4. What components are most promising? Hypotheses

a. More time to reflect on the feedback – b. Level of aggregation of feedback data should be aligned to performance to be

changed c. Tie A&F targets to team based or organisational goals d. Engage recipients in iteratively designing and implementing A&F

5. What are mechanisms of action of A&F interventions e.g. time may work e.g. identify goals for improvement, plans to improve performance, greater depth of processing

6. How to standardise language for describing A&F interventions?

Additional elements: structure

• Goal/standard/audit• Feedback• Action plans• Characteristics of recipients• General/external aspects• Mechanism

Additional elements – Goal/Standard/Audit

• Visibility of required behaviour• Modifiability of behaviour e.g. co-morbidity of patients,

extent to which it is automated , habit strength• Engagement with setting the goal• Number of goals• Quality of goal• SMART goals

Feedback• Competence of deliverer e.g. how to give feedback

• Seriousness of outcome

• Profile/importance of outcome in society

• Salience/vividness/emotional connotations of feedback

• Behaviour

• Recipient seeks feedback rather than passively receiving it

• Multiple behaviours

• Framing – positive vs negative/ gain vs loss

• Complexity of target (different types, draw on theory)

• Credibility of source

• Goal orientation (motivation, mastery vs learning) of recipients

• Intrusiveness of intervention vs part of daily routine

• Visibility of feedback

• Timeliness

Feedback ctd

– Interpretation, time to review, – Opportunity to reflect and discuss (e.g on causes of behaviour,

instances of successful performance) – Support from management/ leaders for feedback– Graded feedback, starting positively– Multi-modality– Format re. new media– Linked to key messages– Feedback to teams– Longitudinal feedback – to tell a story

Action plan

• Involvement with creating action plans• Nature of action plans e.g. if-then plans

Characteristics of recipients• Past experience of audit and feedback as more or less useful• Alignment with goals/values etc of recipient re. receiving feedback and changing behaviour• Knowledge of goals and why they are there• Allegiance of goal• Perceived social comparison with group and individuals/ social norm • Trust in organisation• Autonomy of recipient• Intuitive vs reflective orientation• Learning style• Authority of recipient• Organisation/ self-regulation of recipient• Educational level/ reflectiveness• Responsibility for practice• Union membership

General/External aspects

• Combine with other interventions e.g.– Financial or other consequences of A&F – Whether A&F evaluated

• Automation of practice• Preparation/anticipation for intervention e.g. present audit

details and that you will be assessed• Time spent on intervention• Engagement in designing A&F• Alignment with goals/values etc of recipient

Mechanism

• Relationship between components and outcome e.g. curvilinear

What is “intrinsic” to A&F?

• Prototypical - Components of audit & feedback • Discretionary – action plans, modes of delivery• Assumptions

– that being used for a group that are motivated to change their practice

– interactions between co-interventions and how intrinsic factors work

– minimal standard for feedback - comparison data, feedback of recent performance, include written/visual feedback

Criteria for selecting/prioritising

• Empirical findings• Theory/principles from relevant

literature/disciplines• Dominant beliefs/Frequent current practice• Practitioner experience

Testable hypotheses

1. Level of aggregation of feedback data should be aligned to performance to be changed – individual vs practice/team

2. Complexity/nature of feedback re. number of indicators reported on number of behaviours; bundles; order/priority of indicators; tailoring

3. Format of feedback

4. Mode of delivery of feedback – eg. Paper, electronic, social

5. Frequency of feedback

6. Time to reflect/act on feedback

7. Engagement in design and delivery of feedback vs top down

8. Role for intermediate outcomes/process measures

9. Providing information/commentary alongside the feedback to add to /interpret the feedback

10. Including action plans – type e.g. if-then

11. Training of recipients of feedback

Constraints/ considerations – criteria to use to select what to study

1. Cost

2. Current priorities and policies

3. Current practice and possibilities e.g. re. quality of data, measures

4. Feasibility and screening work

5. Designs to 1. translate activity into evidence

2. maximise number of components to test within resources

6. Sample size – collaborations across groups