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Table 3 How, why and in what circumstances is NCA feedback used to stimulate quality improvement

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

Context Mechanism Impact / Outcome
In what circumstances For whom NCA Resource Provider Response
NHS Trusts operate in a context of competition, public choice and funding initiatives designed to stimulate quality improvement. Trust Boards and their sub-committees that have oversight of clinical services across their organisation. Trust Boards are notified via the NCA supplier if a clinical service is to appear as an outlier in the publically available annual report. Reputation The Trust Board acts to preserve Trust reputation for providing safe and effective care, particularly in response to measures considered publically sensitive in nature. Data interrogation to establish cause of the outlier status, which may lead to more frequent monitoring of the clinical service for assurance.
Professional groups within Trusts have different improvement priorities, and power to support service changes. Clinicians who trust that the feedback is accurate as they upload data to the NCA supplier directly, but do not monitor measures via the NCA supplier website routinely due to constraints on their time. The public report produced by NCA suppliers offers national benchmarks against which to compare service performance. Professionalism: Clinicians incorporate the NCA report into the service’s clinical governance processes, to assess service performance and where improvements can be made. Supplier feedback highlights if the service is an outlier in comparison to peer organisations. The clinical service makes changes to improve their performance, where resources allow.
Tertiary centres that compete with other organisations for patient referrals from district hospitals. The public report produced by the supplier enables services to benchmark their performance against peer organisations in target-based measures. Competition: The clinical service uses the feedback to evidence competitive performance to feeder services. Feeder services may choose to refer more patients to the centre. Clinical teams may act to improve performance to attract patient referrals.
  Clinical services resourced to collect accurate and timely data + to maintain local databases where NCA data is stored prior to upload to the NCA supplier Audit support staff customise feedback using local data i.e. without national comparators. Measures considered important for professionalism and/or to obtain incentives (financial or accreditation) are integrated into the service’s monitoring processes. Clinical staff can quickly identify rises in unwanted incidents or delays in treatment times, introduce change to improve performance, where resources allow, and asses the impact of the change.
Junior doctors and nurses are expected to complete projects as part of their placement within the clinical service. NCAs (via supplier or local databases) offer data that can be used to address trainees’ research questions. Professional development – with support from audit support staff, trainees extract raw data for their projects. Projects provide learning about the service that may highlight how it can be improved. Knowledge/lessons from research projects might be used to inform service delivery.