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  • Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya

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Research
Does audit and feedback improve the adoption of recommended practices? Evidence from a longitudinal observational study of an emerging clinical network in Kenya
  1. Susan Gachau1,
  2. Philip Ayieko1,
  3. David Gathara1,
  4. Paul Mwaniki1,
  5. Morris Ogero1,
  6. Samuel Akech1,
  7. Michuki Maina1,
  8. Ambrose Agweyu1,
  9. Jacquie Oliwa1,
  10. Thomas Julius1,
  11. Lucas Malla1,2,
  12. James Wafula1,
  13. George Mbevi1,
  14. Grace Irimu1,3,
  15. Mike English1,2
  16. on behalf of the Clinical Information Network author group
    1. 1 Kenya Medical Research Institute (KEMRI), Wellcome Trust Research Programme, Nairobi, Kenya
    2. 2 Nuffield Department of Medicine, University of Oxford, Oxford, UK
    3. 3 Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
    1. Correspondence to Susan Gachau; sgachau{at}kemri-wellcome.org

    Abstract

    Background Audit and feedback (A&F) is widely used in healthcare but there are few examples of how to deploy it at scale in low-income countries. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of A&F delivered as part of a wider set of activities to promote paediatric guideline adherence.

    Methods We analysed data collected from medical records on discharge for children aged 2–59 months from 14 Kenyan hospitals in the CIN. Hospitals joined CIN in phases and for each we analysed their initial 25 months of participation that occurred between December 2013 and March 2016. A total of 34 indicators of adherence to recommendations were selected for evaluation each classified by form of feedback (passive, active and none) and type of task (simple or difficult documentation and those requiring cognitive work). Performance change was explored graphically and using generalised linear mixed models with attention given to the effects of time and use of a standardised paediatric admission record (PAR) form.

    Results Data from 60 214 admissions were eligible for analysis. Adherence to recommendations across hospitals significantly improved for 24/34 indicators. Improvements were not obviously related to nature of feedback, may be related to task type and were related to PAR use in the case of documentation indicators. There was, however, marked variability in adoption and adherence to recommended practices across sites and indicators. Hospital-specific factors, low baseline performance and specific contextual changes appeared to influence the magnitude of change in specific cases.

    Conclusion Our observational data suggest some change in multiple indicators of adherence to recommendations (aspects of quality of care) can be achieved in low-resource hospitals using A&F and simple job aides in the context of a wider network approach.

    • audit and feedback
    • quality improvement indicators
    • performance change.

    This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

    https://doi.org/10.1136/bmjgh-2017-000468

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      Footnotes

      • Handling editor Soumitra Bhuyan

      • Contributors All authors contributed to data collection and network activities. ME conceived the idea of the analyses and SG took primary responsibility for and conducted the analyses with support from PA, MO, PM, LM and TJ. SG drafted the initial manuscript with support from ME and PA and feedback on the analytic approach was provided by MM, JO, SA, AA, JW and GI with feedback on subsequent manuscript drafts provided by all authors who then all approved the final daft.

      • Funding This work was supported by funds from the Wellcome Trust (#097170) awarded to ME as a Senior Fellowship together with additional funds from a Wellcome Trust core grant awarded to the KEMRI-Wellcome Trust Research Programme (#092654). Funders had no role in drafting or submitting this manuscript.

      • Competing interests None declared

      • Ethics approval KEMRI Scientific and Ethical Review Committee.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Collaborators The Clinical Information Network author group who contributed to the network’s development, data collection, data management, implementation of audit and feedback and who reviewed and approved this publication includes: Boniface Makone, Mercy Chepkirui, Timothy Tuti, Abraham Lagat (KEMRI-Wellcome Trust Research Programme); Samuel N’gar N’gar (Vihiga County Hospital), Ivan Muroki (Kakamega County Hospital), David Kimutai and Loice Mutai (Mbagathi County Hospital), Caren Emadau and Cecilia Mutiso (Mama Lucy Kibaki Hospital), Charles Nzioki (Machakos Level 5 Hospital), Francis Kanyingi and Agnes Mithamo (Nyeri County Hospital), Margaret Kuria (Kisumu East County Hospital), Sam Otido (Embu County Hospital), Grace Wachira and Alice Kariuki (Karatina County Hospital), Peris Njiiri (Kerugoya County Hospital), Rachel Inginia and Melab Musabi (Kitale County Hospital), Hilda Odeny (Busia County Hospital), Grace Ochieng and Lydia Thuranira (Kiambu County Hospital); Priscilla Oweso (Vihiga County Hospital), Ernest Namayi (Mbale Rural Health and Demonstration Centre), Benard Wambani, Samuel Soita (Kakamega Provincial General Hospital), Joseph Nganga (Mbagathi District Hospital), Margaret Waweru, John Karanja (Kiambu County Hospital), Susan Owano (Mama Lucy Kibaki Hospital), Esther Muthiani (Machakos Level 5 Hospital), Alfred Wanjau (Nyeri Level 5 Hospital), Larry Mwallo (Kisumu East District Hospital), Lydia Wanjiru (Embu Provincial General Hospital), Consolata Kinyua (Karatina District Hospital), Mary Nguri (Kerugoya District Hospital) and Dorothy Munjalu (Kitale District Hospital).

      • Correction notice This article has been corrected since it was first published. The ninth author’s first name was misspelt during article submission. The correct spelling is Jacquie Oliwa.