Audit and feedback of therapist-assisted internet-delivered cognitive behaviour therapy within routine care: a quality improvement case study

Heather D. Hadjistavropoulos*, Jaime Williams, Kelly Adlam, Kerry Spice, Marcie Nugent, Katherine M. B. Owens, Christopher Sundström, Blake F. Dear, Nickolai Titov

*Corresponding author for this work

    Research output: Contribution to journalArticlepeer-review

    3 Citations (Scopus)
    12 Downloads (Pure)


    With the growing use of ICBT in routine care clinics there is a need for literature on how to monitor and improve the quality of therapist behaviours in clinical practice. In this paper, we first provide background literature on Audit and Feedback (A&F), a common quality improvement technique, and then present a case study regarding the use of A&F to improve quality of therapist behaviours in emails sent to patients provided with ICBT in routine care. The A&F measure used was derived from previous research on therapist's email behaviours in ICBT. Fifteen undesirable therapist behaviours (e.g., Did Not Message, Unresponsive to Symptom Increase, Does Not Address Patient Concern) were audited in 1840 emails sent from eight therapists to 198 randomly selected patients, representing 18% of 1114 patients who started between one and five lessons of ICBT in the previous year and did not formally withdraw from treatment (n = 31 patients). The therapists who were audited were provided feedback four times over a one-year period from October 2018 to September 2019. Overall, in all audit periods, we found a low percentage of undesirable therapist behaviours (i.e., therapists displayed the behaviour in 12% or less of the total emails sent). For most therapist behaviours, we saw a trend towards improvement across the four audit cycles. Three therapist behaviours (i.e., Failure to Ask One Question to the Patient, Poor Instructions, Not Linking Email to Course Content) did not follow this pattern and were flagged for clinical discussion to determine why behaviours were elevated and whether these behaviours represented unrealistic expectations. The process was valuable for monitoring and improving therapist behaviours and highlights the need for future research on standards for therapist behaviours (e.g., which behaviours to focus on, setting acceptable levels of undesirable behaviour).

    Original languageEnglish
    Article number100309
    Pages (from-to)1-9
    Number of pages9
    JournalInternet Interventions
    Publication statusPublished - Apr 2020

    Bibliographical note

    Copyright the Author(s) 2020. Version archived for private and non-commercial use with the permission of the author/s and according to publisher conditions. For further rights please contact the publisher.


    • internet-delivered cognitive behaviour therapy
    • audit and feedback
    • quality improvement
    • therapist behaviours


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