Background The National Prostate Cancer Audit (NPCA) reports publicly performance indicators for all hospitals in England and Wales providing radical prostate cancer treatment, identifying those with results that fall outside the ‘accepted range’ as ‘potential negative outliers’. Hospitals with outlying results are requested to provide a formal response.

This ‘outlier process’, targeting a limited number of hospitals, mirrors a ‘high-risk approach’ of preventing poor quality care in contrast to a ‘population approach’ that would target all hospitals. We invited clinicians to a national workshop to learn how the outlier process contributes to quality improvement.

Methods The workshop started with presentations on reducing the ‘toxicity’ of radical prostate cancer treatment. Then, clinicians from three hospitals identified as outliers shared their experience of the process and the changes in practice they had made as a result. We collected data in three ways. First, an online platform was used to gather comments from participants during the workshop. Second, a number of participants were interviewed about the outlier process as a means to improve quality of care. Third, feedback was sought after the workshop from all participants. Responses were collated and analysed for themes.

Results Sixty-nine clinicians attended including urologists, oncologists, radiographers and nurses, representing a spread of hospitals across England and Wales. There were 6 interviews, 21 online comments and 31 responses after the workshop. The clinicians representing outlying hospitals highlighted the negative (stigma, work load, negative impact on reputation) and the positive impact (detailed review of procedures, implementation of targeted approaches) of the outlier process. Participants felt that sharing experiences of outlying hospitals helps others to improve. They also suggested a ‘buddy system’ between better and worse performing hospitals. Many highlighted the importance of ‘networks’ to share experiences, either good or bad, as a vehicle for improving practice.

Discussion The outlier process was generally accepted as a possible mechanism to improve practice. However, participants indicated that effective dissemination is key to ensuring that identifying poor outcomes in some hospitals (e.g. high-risk approach) can stimulate country-wide quality improvement (population approach).