Revitalising audit and feedback to improve patient careBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m213 (Published 27 February 2020) Cite this as: BMJ 2020;368:m213
All rapid responses
Thanks for this article about audit, describing some of the frustrations with current practice as well opportunities and potential impact.
Recognising that a plethora of quality indicators or audit standards can make it hard to focus on what really matters, we have chosen to identify a handful of success statements or core capabilities which we believe are necessary and sufficient to achieving good outcomes and experience at end of life. Being clear about “what” we’re trying to achieve together (and why) makes it easier for us to be creative about “how” it’s achieved. Regularly reflecting on how confident we are that these success statements are true, what makes them harder to achieve and what would make them easier, creates clarity of purpose and helps us to identify and work on key points of leverage.
It brings shared learning and improvement into everyday work and has helped to build camaraderie within the team, as well as fostering relationships and collaboration with others.
We’ve written more about this practice here in comparison with more traditional audits: https://www.nextstageradicals.net/blog/improving-end-of-life-care-what-d... and are interested to hear what others think.
The principles behind this approach could be applied in contexts; we’re aware of similar approaches being used to transform pathology services and home care, amongst others.
Competing interests: No competing interests
We read with interest the recent article by Foy et al summarising the challenges and opportunities for using audit and feedback to improve patient care. 
We agree that research should be embedded to improve the impact of national audits. In addition to the study designs described by Foy, we would add that an understanding of relevant contextual factors using qualitative methods can help explain how national audits are perceived locally and used for improvement (or not). For instance, recent evaluations of a quality improvement intervention in the UK using data from the National Emergency Laparotomy Audit highlighted the importance of social barriers to change.[2–4]
With this in mind we are conducting a concurrent qualitative process evaluation of the national Perioperative Quality Improvement Programme (PQIP) in the UK, a multidisciplinary initiative supporting local quality improvement to benefit patients undergoing major surgery (www.pqip.org.uk).[5,6] A key aspect of this evaluation is its formative nature – providing the opportunity for the QI programme to evolve rapidly in response to stakeholder feedback. We hope that by understanding the social, organisational and professional contexts with which PQIP operates will help us to refine its implementation and optimise impact.
Duncan Wagstaff (Centre for Perioperative Medicine, UCL; Health Services Research Centre, Royal College of Anaesthetists)
Cecilia Vindrola (Department of Applied Health Research, UCL)
Naomi Fulop (Department of Applied Health Research, UCL)
Ramani Moonesinghe (Centre for Perioperative Medicine, UCL; Health Services Research Centre, Royal College of Anaesthetists)
 Foy R, Skrypak M, Alderson S, et al. Revitalising audit and feedback to improve patient care. BMJ. 2020;368:m213.
 Stephens TJ, Peden CJ, Pearse RM, et al. Improving care at scale: process evaluation of a multi-component quality improvement intervention to reduce mortality after emergency abdominal surgery (EPOCH trial). Implement Sci. 2018;13(1):142.
 Stephens TJ, Peden CJ, Haines R, et al. Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data. BMJ Qual Saf. September 2019.
 Peden CJ, Stephens T, Martin G, et al. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial. Lancet. 2019;0(0).
 Wagstaff D, Moonesinghe SR, Fulop NJ, Vindrola-Padros C. Qualitative process evaluation of the Perioperative Quality Improvement Programme (PQIP): study protocol. BMJ Open. 2019;9(7):e030214.
 Gilhooly D, Moonesinghe SR. The Perioperative Quality Improvement Programme: improving outcomes. Br J Hosp Med. 2018;79(2):117-117.
Competing interests: SRM is PQIP Lead, Director of the Health Services Research Centre (HSRC) at the Royal College of Anaesthetists, and associate National Clinical Director for elective care, NHS England. DW is a PQIP Fellow at the HSRC.