• 13 January 2020
  • 3 min read

Improving healthcare through advancing the evolution of audit and feedback

The nature of human behaviour – and how people change their behaviour – has fascinated Eilidh ever since she began studying health psychology.


As human beings, we’re always looking for feedback on our behaviour.

We check our watch when we leave the house in the morning to see if we’re on track to make our 9am meeting. We scan the departures board when we arrive at the station to see if our train is scheduled to leave on time.

And we may change our behaviour based on the feedback we get.

If our watch says 8:32am, we might walk a little more quickly to the station. If our train is delayed or cancelled, we might try and find a different route – or even call to reschedule the meeting.

“The different feedback we receive along the way can make us change our behaviour and reassess our end goal,” explains Dr Eilidh Duncan.

The nature of human behaviour – and how people change their behaviour – has fascinated Eilidh ever since she began studying health psychology. And for the past 10 years, she has applied that interest to a wide range of projects while working in the University of Aberdeen’s health services research unit.

Eilidh is particularly interested with how behaviour change can help improve healthcare practice, which makes her current research on audit and feedback strategies a natural fit.

In audit and feedback, a healthcare provider’s performance is measured, and results are fed back to them. Seeing gaps between their performance compared with expected standards of care, and maybe compared with the performance of others, is meant to motivate healthcare providers to change their behaviour to try and close the gap – just as checking our watch can motivate us to speed-walk through a busy train station.

Audit and feedback has shown a lot of promise in addressing the tricky challenge of how to get research findings into practice. A study by Eilidh and her Aberdeen colleagues found that audit and feedback interventions led dentists across Scotland to reduce their antibiotic prescribing by 6%.

“That may not sound like a lot, but it relates to 20,000 fewer antibiotic prescriptions,” Eilidh says.

But audit and feedback interventions aren’t always effective, and we still don’t fully understand when, why, and how they work.

One of the biggest questions marks is around how feedback should be delivered. At the moment, feedback can be verbal, written, and electronic. It can come from a variety of sources – some more trusted than others. And it can be presented in different ways, sometimes accompanied by a short, actionable statements that reinforce best practice.

“It can look quite different depending on which options people choose,” Eilidh explains.

How audit and feedback is designed and delivered is likely to influence how it is received and acted upon. The wrong messaging can make the target healthcare professional defensive or dismissive, and reduce the likelihood they change their behaviour. That’s partly why co-designing strategies with the healthcare providers has become a priority area for research in the audit and feedback community. Can co-design ensure that audit and feedback interventions are clinically meaningful, actionable, and user-friendly? Can it help get the tone and messaging of the feedback right? In short, can co-design make audit and feedback more effective?

Eilidh will attempt to answer some of these questions during her THIS Institute post-doctoral fellowship. As part of her fellowship project, she will work with Scottish dental health professionals to co-design and pilot audit and feedback tools. She will also explore how audit and feedback is currently used in Scotland at an organisational level, by interviewing health policymakers and analysing existing tools.

Her findings could have wide implications for how audit and feedback is used across different healthcare settings and across the world. She is also excited about the project’s potential to have a more focused impact on an often-overlooked aspect of healthcare.

“Dental healthcare tends to be treated as lower priority,” she says. “But if you consider the impact between oral health and general health, it’s very important,” she says.

The audit and feedback interventions designed as part of Eilidh’s project will target two key clinical areas: antibiotic prescribing and fissure sealant placement. Both areas demonstrate unwarranted variations in practice, with dentists overprescribing antibiotics and underusing fissure sealants. And improving both areas could make a difference for people’s health, by reducing the risk of antimicrobial resistance and preventing tooth decay.

“There’s definite scope for improvement, which makes it a very satisfying area to work in,” Eilidh says.


Learn more about Eilidh Duncan’s research.