Improving Clinical Outcomes: A Study of the Impact of Audit and Feedback on Nurse Performance
Rebecca Clark, PhD, MSN, BSN, RN; Kimberly Ferren Carter
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Purpose: The purpose of this project was to explore the impact of timely, individualized audit and feedback on clinical outcomes and nursing behaviors. The specific focus of the study was to improve the pneumococcal immunization rate for at-risk adults in ambulatory settings. The objective of the study was to increase immunization rates to 50% for eligible patients.
Background: While vaccines are noted to be among the most successful health advances in recent history, adult immunization rates in the United States are well below the recommended levels. The economic and personal costs far outweigh the cost of effective immunizations but studies continue to indicate the need for effective strategies to immunize our at-risk groups. Centers for Disease Control and Prevention estimates that only 20% of the at-risk population ages 19 to 64 has been immunized, contrasted with 61% of those greater than age 65.
While adults are often hesitant to obtain vaccines, the literature indicates that providers may avoid administering the vaccines per immunization schedule. Studies have demonstrated that interventions targeted toward provider behavior on a variety of patient care issues can have a major impact on improving implementation of practice guidelines.
Studies have shown that individualized assessment (audit) and feedback (A & F) can be effective in improving outcomes in numerous settings. Effective A&F interventions includes key components of timeliness, individualization, and nonpunitiveness. This study explored the impact of audit and feedback on individual performance and the clinical outcome of pneumococcal immunizations.
Study: This study was deemed a quality improvement study by the Institutional Review Board, and consent was not required. The study was conducted from October 2014 to August 2015.
Setting: This study was conducted in a presurgical testing center (PST) that is a department of a large healthcare system in southwestern Virginia. This center is a referral site for the region and has over 12,000 patient visits annually. The PST is staffed by RNs who conduct risk assessment on patients prior to surgeries. The departmental goal for immunizations was set at 50% of eligible patients and each staff member had this as an individual goal.
All patients seen in the PST were screened for eligibility for the pneumococcal vaccine per Centers for Disease Control criteria:18 years of age or older, history of chronic disease, and/or smoker. At the time of the study only the Pneumovax 23 immunization was recommended by the CDC. The staff were educated regarding the importance of the vaccine and how to use the electronic medical record (EMR) to determine patient eligibility for the vaccine.
This study consisted of 2 phases: Phase 1) feedback to staff regarding personal performance for the previous year and Phase 2) individual audit and feedback that reflected the individual performance for the previous month.
Results and Analysis: Data were collected for nine months, and analyzed for Phase 1, Phase 2 and the total study using chi square. The mean immunization rate from the preceding fiscal year (November 2013 through October 2014) served as the control and was 41.68%.
Phase 1: The nurse manager provided staff members with data about individual performance for the previous 12 months (November 1, 2013 to October 31, 2014). For the three months following this feedback (November 2014 through January 2015) the mean departmental immunization rate was 32% (range: 27% to 32%). This was not statistically significant X2 (1, N=614) =1.74, p=1.86 when compared with the control.
Phase 2: Phase 2: From February through August 2015, the manager provided each staff member with a monthly email that detailed the personal rate of administration of vaccines to eligible patients. Data for these emails were generated though reports based on the EMR.
During this six-month period, the mean departmental immunization rate rose to 56.8% (range 45% to 67%). This individual, timely feedback was significant X2 (1, N=1379) =4.50, p=0.033.
The impact of the intervention for both phases of the study was 49%. The result was not significant X2 (1, N=1993) =0.98, p=.32.
Discussion: The purpose of this project was to improve the immunization rates for adults to 50% using audit and feedback on nurses’ performance. This goal was achieved in the second phase of the study where the clinical outcomes (immunization rates) for the department were significantly higher.
These findings support the hypothesis that timely, individualized audit and feedback that is not punitive can have a positive impact on the departmental outcome of immunizations. Generalized feedback that does not provide information that is actionable did not have the same impact. Staff commented to the nurse manager that the 12-month data point was not something they could impact. However, they noted that the monthly emails provided them with data about current performance that they could change.
It was not possible to assess the impact on individual performance due to variations in staffing. For example, within the six-month time frame of the study, several nurses rotated to clinical leadership positions and did not administer vaccines, while others were on extended leave. This resulted in a small sample size of nurses who worked in a consistent role over the period of the study.
Limitations: Generalizability is limited due to the time frame for this study. More study is needed to understand the sustainability and impact of these findings. The trend in this study supports that timely, actionable feedback, provided by a manager, has a positive impact on individual behavior related to immunizations of eligible patients. Further study regarding the impact of individualized audit and feedback will yield a deeper understanding.
Conclusion: Individual variations in practice account for variations in clinical outcomes. In efforts to improve patient care and clinical outcomes, it is important to influence individual provider efforts to encourage compliance with guidelines. It is essential for providers to have actionable information about their behavior if they are to improve.
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