"My approach to this job is...one person at a time": Perceived discordance between population-level quality targets and patient-centred care.

OBJECTIVE: To understand the usefulness of audit and feedback among family physicians and examine the barriers to using it to improve quality of care. DESIGN: Qualitative study using in-depth interviews. SETTING: Family physicians across Ontario participating in audit and feedback initiatives describing the proportion of patients meeting quality targets for chronic disease. PARTICIPANTS: Purposive sampling was conducted to ensure variation in sex, years of experience, and baseline performance for quality metrics. All participants used electronic medical records and worked in multidisciplinary primary care practices. METHODS: Semistructured interviews were conducted with family physicians. The interview guide and initial coding framework were adjusted iteratively in keeping with the constant comparative method. Sampling continued until saturation was reached. Interviews were analyzed using the framework approach. MAIN FINDINGS: Participants reported that the feedback increased their awareness of gaps between ideal and actual performance. This resulted mainly in efforts to "try harder" patient by patient. Key barriers to acting upon feedback in a systematic manner included a perceived discordance between population-level quality targets and patient-centred care, as well as competing priorities at both the patient and organizational levels. Although all participants had electronic medical records, participants reported a lack of quality improvement infrastructure in their practices. CONCLUSION: Family physicians were not highly motivated to achieve evidence-based population-level quality targets for diabetes; many competing organizational and clinical goals took priority. Additional human resources might be needed to translate data in feedback reports into systematic changes that could lead to sustained improvements in quality of care.