Title: Enhancing audit and feedback in acute Trust dementia care
Funder: Department of Health and Social Care

Abstract: BACKGROUND People with dementia do not receive National Institute for Health and Care Excellence-defined best care, including assessments of functioning, nutrition and pain. Dementia affects over 676,000 people in England and 25-40% of in-patients in acute hospitals have a diagnosis of dementia. Evidence-based care for people with dementia is a priority for patients, carers, clinicians and policy-makers. Audit and feedback (A&F) is a commonly-used and variably effective intervention to improve care. A&F achieves improvement in diverse clinical behaviours, for example, in clinical assessments and prescribing. A&F involves comparing current care against an evidence-based standard, and giving feedback to staff on whether it meets those standards. My systematic review of A&F in dementia care found that studies are of poor quality and show gaps in reporting. This hinders the ability to draw conclusion about effectiveness. A recent Cochrane review of A&F in different clinical domains found that while A&F led to a relatively small 4.3% median absolute improvement in the delivery of clinical behaviours, it had the potential to result in large effects (interquartile range 0.5% to 16%). The Cochrane review described a number of influences upon the effectiveness of A&F, and called for research into how A&F can be enhanced to provide greater improvement. The current proposal responds to this call by generating enhancements to improve the effectiveness of A&F. OBJECTIVES 1. To describe the current audit and feedback practices (content, delivery and contextual influences upon them) in caring for people with dementia in acute hospitals 2. To develop enhancements to current audit and feedback interventions in order to increase the receipt of evidence-based care by patients with dementia. 3. To develop a Trust-level strategy to implement the enhancements. 4. To explore the feasibility of implementing the enhancements in one hospital. RESEARCH QUESTION How can audit and feedback be enhanced to increase the level of evidence-based care that patients with dementia receive in acute hospitals?PLAN OF INVESTIGATION Three consecutive phases using mixed methods and co-production applying Medical Research Council (MRC) guidance for the development and evaluation of complex interventions will be followed: Phase 1, Describing A&F practices', will consist of concurrent documentary analysis, interviews and observations. The documents, interview participants and observations will be from different organisational levels. The data will be analysed using framework analysis and synthesised into a conceptual model of A&F in caring for people with dementia in acute hospitals by a co-production group. The co-production group will include three patients or carers, three dementia care staff and three staff leading A&F. Phase 2, Co-production of enhancements to A&F', will involve the co-production group generating enhancements and an implementation strategy. They will attend five structured workshops where nominal group technique will be used to draw on the findings from Phase 1 and previous research findings to generate enhancements. Normalisation Process Theory will underpin the implementation strategy. Phase 3, Feasibility test and subsequent refinement', will involve four multilevel mixed-methods case studies, informed by generic case study methodology and the MRC process evaluation guidance. The co-production group will use these finding to refine the enhancements and implementation strategy. POTENTIAL BENEFITS Co-producing evidence-based enhancements to A&F and a theory-informed strategy for implementing these enhancements will be a significant step towards achieving improved outcomes for patients. Generating a conceptual model of A&F in caring for people with dementia will inform future research about implementation. New knowledge about the feasibility of an intervention to implement enhancements to A&F will inform a later effectiveness trial. Disseminating new knowledge about the use of co-production to integrate evidence and theory will improve stakeholder involvement, a key component in the development of complex interventions.

Lay abstract: Background: More than one in four people in acute hospitals have dementia. Patients with dementia do not always get the best care, for example their pain is not assessed and they are not asked about what they eat and drink. To improve care, hospitals assess (audit') current care and provide staff with feedback' about how well they are doing. Hospitals use audit and feedback' a lot.How much good audit and feedback' does varies. Doing audit and feedback in the best way would result in better care for patients with dementia. It could also be used to improve the care for other patient groups. At present, there are many questions about audit and feedback in dementia care. These questions include: How is it done? How could it be improved? How can we make these improvements happen in practice? This research will seek answers to these questions. It will then be important to see whether making the improvements happen in this way leads to better care for patients. We will therefore also do a practice study to explore making the improvements. Aims: (1) To describe audit and feedback' in the care of people with dementia in acute hospitals. (2) To design improvements to audit and feedback. (3) To design a way to make the improvements happen. (4) To study whether the improvements can be made in one hospital. Research question: How can we do audit and feedback' better to improve hospital care for people with dementia? Design: During this research I will work with patients or carers, hospital staff (doctors, nurses or other care staff) and people who lead audit and feedback in dementia care. These people will form a group called the co-production group'. Researchers who are experts in improving healthcare will also provide advice to the co-production group. Four hospitals will be involved in this research. The research will be done in three parts: Part 1: I will ask hospital staff what currently happens in audit and feedback. I will also observe what happens, and I will study what is written about audit and feedback. I will share what I learn with the co-production group, and together we will draw a diagram of what happens across the different hospitals. Part 2: The co-production group will use the diagram from Part 1, and findings from previous studies, to design improvements to audit and feedback. They will discuss ideas for improvements, and agree what makes a good improvement. Finally, the group will discuss the best way to make the improvements happen, for example, by training people who do audit and feedback. Part 3: We will see if we can make the improvements happen in one hospital, and study the experience and process of doing so. I will observe what happens and ask people for their views. I will tell the co-production group about how the improvements have been made. The group will then discuss whether the improvements need further work and whether we should change how we make them happen.At the end of the study, we will be able to say whether it is a good idea to have a further formal study to test the improvements in a wider range of hospitals. Patient involvement: I will look for three patients or carers to join the co-production group. This coproduction group will help me develop the diagram of audit and feedback in dementia care. They will also advise me on where further information is needed and how to get this. The group will then develop the improvements to audit and feedback and consider how to make them happen in the hospital. The group will help describe the study and what we find. Dissemination: The co-production group will be asked to join me in presenting results to interested audiences. We will present to different audiences, including to patient and carer groups, researchers and service providers. I will write about the findings in journals. I will also arrange a meeting for people who provide, buy or monitor health services. People involved in this study will also be invited to this meeting. The co-production group and I will describe the study findings at this meeting. We will also share the results via video-recorded messages on social media.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: NEUROLOGICAL