Effects of audit and feedback delivered within an emerging clinical network in Kenya on multiple indicators of the process of paediatric hospital care – a longitudinal observational study.

Background: Audit and feedback (A&F) is a widely used method to promote quality improvement in healthcare but how to optimize its use for best effects still requires research. Establishing the Clinical Information Network (CIN) in Kenya provided an opportunity to examine the effect of Audit and feedback delivered as part of a wider set of activities to improve clinical processes of care. Methods : We analysed data collected from medical records on discharge for children aged 2-59 months from 14 Kenyan first referral-level hospitals in the CIN. Hospitals joined CIN in phases and for each we analysed their initial 25 months of CIN participation that occurred between December 2013 and March 2016. A total of 34 indicators were selected for evaluation each classified by form of feedback (passive, active, and none) and type of task (simple or difficult documentation and those requiring cognitive work). Performance change was explored graphically and using generalized linear mixed modes models with attention given to the effects of time and a standardized paediatric admission record (PAR) form. Results : Data from 60,214 admissions were eligible for analysis.  Performance across hospitals significantly improved for 24/34 indicators. Performance improvement was not obviously related to nature of feedback, may be related to task type, and was related to PAR use in the case of documentation indicators.  There was marked variability in performance change across sites and indicators, low baseline performance and specific contextual changes appeared to influence the magnitude of change in specific cases. Conclusion : Our observational data suggest change in multiple process indicators of quality can be achieved in low resource hospitals using network approaches, audit and feedback and simple job aides.