Examining clinical performance feedback in patient-aligned care teams

BACKGROUND: The move to team-based models of health care represents a fundamental shift in healthcare delivery, including major changes in the roles and relationships among clinical personnel. Audit and feedback of clinical performance has traditionally focused on the provider; however, a team-based model of care may require different approaches. OBJECTIVE: Identify changes in audit and feedback of clinical performance to primary care clinical personnel resulting from implementing team-based care in their clinics. DESIGN: Semi-structured interviews with primary care clinicians, their department heads, and facility leadership at 16 geographically diverse VA Medical Centers, selected purposively by their clinical performance profile. PARTICIPANTS: An average of three interviewees per VA medical center, selected from physicians, nurses, and primary care and facility directors who participated in 1-hour interviews. APPROACH: Interviews focused on how clinical performance information is fed back to clinicians, with particular emphasis on external peer-review program measures and changes in feedback associated with team-based care implementation. Interview transcripts were analyzed, using techniques adapted from grounded theory and content analysis. KEY RESULTS: Ownership of clinical performance still rests largely with the provider, despite transitioning to team-based care. A panel-management information tool emerged as the most prominent change to clinical performance feedback dissemination, and existing feedback tools were seen as most effective when monitored by the nurse members of the team. Facilities reported few, if any, appreciable changes to the assessment of clinical performance since transitioning to team-based care. CONCLUSIONS: Although new tools have been created to support higher-quality clinical performance feedback to primary care teams, such tools have not necessarily delivered feedback consistent with a team-based approach to health care. Audit and feedback of clinical performance has remained largely unchanged, despite material differences in roles and responsibilities of team members. Future research should seek to unpack the nuances of team-based audit and feedback, to better align feedback with strategic clinical goals.