Feedback on clinical team performance: how does it work, in what contexts, for whom, and for what changes? A critical realist qualitative multiple case study

Abstract

Background: Feedback on clinical performance aims to provide teams in health care settings with structured results about their performance in order to improve these results. Two systematic reviews that included 147 randomized studies showed unresolved variability in professional compliance with desired clinical practices. Conventional recommendations for improving feedback on clinical team performance generally appear decontextualized and, in this regard, idealized. Feedback involves a complex and varied arrangement of human and non-human entities and interrelationships. To explore this complexity and improve feedback, we sought to explain how feedback on clinical team performance works, for whom, in what contexts, and for what changes. Our goal in this research was to present a realistic and contextualized explanation of feedback and its outcomes for clinical teams in health care settings. Methods: This critical realist qualitative multiple case study included three heterogeneous cases and 98 professionals from a university-affiliated tertiary care hospital. Five data collection methods were used: participant observation, document retrieval, focus groups, semi-structured interviews, and questionnaires. Intra- and inter-case analysis performed during data collection involved thematic analysis, analytical questioning, and systemic modeling. These approaches were supported by critical reflexive dialogue among the research team, collaborators, and an expert panel. Results: Despite the use of a single implementation model throughout the institution, results differed on contextual decision-making structures, responses to controversy, feedback loop practices, and use of varied technical or hybrid intermediaries. Structures and actions maintain or transform interrelationships and generate changes that are in line with expectations or the emergence of original solutions. Changes are related to the implementation of institutional and local projects or indicator results. However, they do not necessarily reflect a change in clinical practice or patient outcomes. Conclusions: This critical realist qualitative multiple case study offers an in-depth explanation of feedback on clinical team performance as a complex and open-ended sociotechnical system in constant transformation. In doing so, it identifies reflexive questions that are levers for the improvement of team feedback.