Commentary On “Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms”

Jan 12,2024 | Christopher M. Shea Commentary

Although audit and feedback strategies are supported by evidence and commonly used, there is a need for more knowledge about why their effectiveness varies and more guidance about how to successfully employ them. Sarkies et al. examine a statewide audit and feedback strategy in Australia to promote value-based care for patients with chronic heart failure, chronic obstructive pulmonary disease, and diabetes. The strategy was employed in more than 100 hospitals to identify their potential areas of focus for quality improvement. Sarkies and colleagues aimed to determine the mechanisms by which effects of audit and feedback were realized and examine the impact of contextual factors on the mechanisms and outcomes. In other words, their study employed a realist design to explain how circumstances surrounding the design of the audit and feedback strategy contribute to the strategy working or not. The authors used a combination of methods, including literature review and document review to specify theories about how the audit and feedback strategy should work as well as data from semi-structured interviews to assess congruent or dissonant findings and refine the theories. Ultimately, the authors propose the “Model for Audit and Feedback Implementation at Scale,” illustrating conditions under which the audit and feedback strategy is successful and unsuccessful. They posit that audit and feedback works well through one of the following mechanisms: (1) triggering ownership and buy-in to the improvement process; (2) helping make sense of clinical performance; (3) creating social influence in the form of peer competition; and (4) assuming responsibility for the audit measures.  According to the model, lack of success occurs through (1) undermining trust in the results; (2) perception of audit as unfair and unachievable; (3) feedback not providing a foundation for quality improvement; and (4) feedback perceived as directive without respect for clinical expertise. Their findings and proposed model are particularly useful because they go beyond identifying important factors for consideration to illustrating how characteristics of the audit and feedback strategy affect behavioral responses to the strategy. I recommend the article as a resource for those looking to employ audit and feedback at any scale.


Sarkies, M., Francis-Auton, E., Long, J., Roberts, N., Westbrook, J., Levesque, J. F., . . . Braithwaite, J. (2023). Audit and feedback to reduce unwarranted clinical variation at scale: a realist study of implementation strategy mechanisms. Implement Sci, 18(1), 71. doi:10.1186/s13012-023-01324-w