When is audit and feedback effective in dementia care? A systematic review.

BACKGROUND: Evidence-based care for people with dementia is a priority for patients, carers and clinicians and a policy priority. There is evidence that people with dementia do not always receive such care. Audit and feedback, also known as clinical audit, is an extensively-used intervention to improve care. However, there is uncertainty about the best way to use it. OBJECTIVES: To investigate whether audit and feedback is effective for improving health professionals' care of people with dementia. To investigate whether the content and delivery of audit and feedback affects its effectiveness in the context of health professionals' care for people with dementia. DESIGN: Systematic review DATA SOURCES: The Cochrane Central Register of Controlled Trials, Prospero, Medline (1946-December week 1 2016), PsycInfo (1967-January 2017), Cinahl (1982-January 2017), HMIC (1979-January 2017), Embase (1974-2017 week 1) databases and the Science Citation Index and Social Science Citation Index were searched combining terms for audit and feedback, health personnel, and dementia. REVIEW METHODS: Following screening, the data were extracted using the Template for Intervention Description and Replication (TIDieR), and synthesised graphically using harvest plots and narratively. RESULTS: Thirteen studies met the inclusion criteria. Published studies of audit and feedback in dementia rarely described more than one cycle. None of the included studies had a comparison group: 12 were before and after designs and one was an interrupted time series without a comparison group. The median absolute improvement was greater than in studies beyond dementia which have used stronger designs with fewer risks of bias. Included studies demonstrated large variation in the effectiveness of audit and feedback. CONCLUSIONS: Whilst methodological and reporting limitations in the included studies hinder the ability to draw strong conclusions on the effectiveness of audit and feedback in dementia care, the large interquartile range indicates further work is needed to understand the factors which affect the effectiveness of this much-used intervention.

Balancing harms in support of recovery.

BACKGROUND: Harm in mental health has traditionally been viewed as "unambiguous" and measured in terms of suicide, self-harm, self-neglect and violence. In order to develop an organisational patient safety strategy, one Trust engaged with service users, carers and senior clinicians and managers in order to understand how they define harm. AIM: To explore the meaning of harm in a mental health and learning disabilities setting. METHOD: This paper describes the outcome of service improvement work with service users, carers, senior clinicians and managers at one Trust to determine what harm meant to them. RESULTS: Harm is a concept which is broader than elements currently seen within organisational patient safety metrics and clinical risk assessments. CONCLUSIONS: Taking into account the diverse feedback received about what constitutes harm, a more inclusive definition emerges which could be incorporated into a new framework for risk management, balancing risk of harms across multiple dimensions. This approach has the potential to bring together consideration of the risk and recovery agendas.