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It helps to understand the validity of a procedure conducted in the past, which becomes a source of reference for the future, and forms what is known as Medical Audit. DEFINITION It is an evaluation system in which established standards are used to measure performance. Once corrective action has been taken about problems identified through a review process, performance is re-measured after an appropriate time period.
It aims to improve the quality of medical care. It compares actual medical practice with agreed standards of practice. It is formal and systematic. It involves peer review. It requires the identification of variations between practice and standards followed by the analysis of causes of such variations. It provides feedback for those whose records are audited It includes following up or repeating an audit some time later, to find out if the practice is fulfilling the agreed standards.
Who is being audited? Who is auditing? What is being audited? How is the audit conducted? How often and when is the audit conducted?
A medical audit committee should be comprised of following professionals from the medical section. • • • • Director of Medical Services. Heads of Medical Departments (Medicine, Surgery, Obstetrics & Gynecology, Paediatrics) Head of Pathology. Nursing Superintendent.
The following from the administrative section: • • CEO/MD Administrator
FREQUENCY OF AUDIT
Periodic/regular: Monthly audit of cases (this includes death cases collected over a month).This periodicity is subject to the patient turnover in the hospital. Surprise checks of medical records conducted fortnightly.
AREAS OF AUDIT
1) Case Audit-Mortality review, Complications audit, Antibiotic utilization, Overstay audit, Investigation audit. Check sheet: pre-operative, pre-anesthetic, pre-procedural. 2) Infection control audit: HAI, Environment infection. 3) Critical areas audit, e.g. ICUs, OT, burns, dialysis. 4) Medical record audit 5) Resource utilization: frequency of consultation, frequency of sample collection, frequency of usage of consumables frequency of usage of OT, diagnostics, physiotherapy, the medico-social Worker. 6) Equipment audit.
1) Case Study: An ideal subject for audit should be a common, well defined, clinically significant diagnosis or treatment. Mortality Review: Autopsies of death cases should be performed. The final diagnosis or the cause of death must be given by the pathologist. Medical records are sealed, so that no alterations can be made. The cases are then opened at the meeting, and the details of the cases sheets are discussed and debated. Complications Audit: Complications occurring must be determined by verifying observations with the drug therapy, or a change in therapy, and laboratory and radio-imageological findings. Antibiotic Utilization: A trial of minimum 3days is mandatory in most cases, before any antibiotic is changed. During the management of any infective disorder, when response to therapy is unsatisfactory, it is appropriate to check the correctness of diagnosis, dosages and acceptance of the prescribed drugs. A policy of instituting drugs for the old, the young, pregnant women and immunocompromised patients is mandatory. Overstay Audit: All interventional and surgical procedures have a fixed period of stay. Any patient’s length of stay beyond these acceptable limits needs to be audited, and the causes for overstay need to be examined. Investigation Audit: The relevance of any investigation prescribed needs to be examined. However, a prescribed set of investigations for specific procedures should be complied with. Thus, a checklist should be prepared for each situation. Check Sheet: In a typical audit, the anesthetists should reach an agreement about what they want to know about their practices, and they should select their objectives accordingly. They should then agree on the number of cases to be included, the time period to be covered, and whether data should be collected on past, present or future cases.
2) Infection Control Audit: 1) Arrange regular swab collection from the environment. 2) Collect samples or swabs from appropriate sources(patients, equipments, personnel)to determine the infection rate. 3) Check whether protocols documented for infection control are being followed e.g cleaning & disinfection, regulation of traffic movement, A/C policy and so on. 3)Critical Area Audit: Specific protocols need to be laid down for the survival and recovery of patients in critical areas, namely in the Operation Theatre, Intensive Care Unit, Dialysis Unit, Burns Unit, Isolation Rooms and Pediatric Recovery Rooms. 4) Medical Record Audit: The purpose of it to ensure that accurate and complete medical records are maintained for every patient treated. Some factors to be considered: • • • • • • • The format of the complete medical record. Forms to be used in the record. The entries should mention the time and date. The charts should be problem- oriented and analytical. The reasons for the actions taken should be mentioned. The methods of retaining and retrieving medical records. The adequacy and accuracy of it must be ensured by the consultant doctors, who should examine them during their ward rounds.
5) Equipment Audit: The scope of the medical audit could be stretched; the audit committee could make valuable contributions, and work out new strategies by curtailing costs without comprising efficiency. Equipment audit serves this purpose. Guidelines should be developed to analyze the need for equipment in a scientific manner.
DIRECT AND INDIRECT Indirect Audit: Indirect audit for patient care consists of a team of heads of departments visiting various areas in the hospital, along with the nursing supervisor and submitting a written report on the following points: • • • • • • • Buildings: aesthetic and functional aspects of in-patient and outpatient areas. Equipment: kinds, age, and state of repair. Supplies: amount, quality and availability. Staff: number, training and efficiency. Statistics: IP and OP statistics every month. Relationship of departments with other departments. Plans: for future departments.
This must be followed by the Medical Superintendent meeting the HOD, and a discussion regarding written reports, resulting in action plans for improvement. Follow-up must be ensured in all areas. DIRECT AUDIT Direct patient care audit is done by a consultant, aided by two senior members of the medical staff. It involves:
• • • • • •
Maintenance of case study records of all deaths cases during the year. Visiting all patients and examining current records. Discussing record-keeping with various clinicians. Visiting the OTs, CSSD,X-ray, etc and supervising the general functioning of the departments Meeting the medical staff and nursing staff initially, and on completion of the audit reporting and discussing results. This type of audit is essentially an internal audit. In addition to this, it is advisable to have an outside agency periodically test the completeness and accuracy of the internal audit.
A) Statistical Method: This should be determined ward wise and unit wise on a monthly basis. It includes: 1) Bed Occupancy Rate: Ideal at 80%. 2) An average length of stay: exceeding 12days indicative of the presence of chronic or incurable patients in a hospital intended for poor medical care, HAI, bottlenecks in investigative procedures. 3) Infection Ratio: a more ratio of more than 2% infection in clean surgical cases calls for investigation. 4) Consultation Rate: Formal consultations should be held for 15 to 20 % of the patients admitted into a general hospital. B) Death or Mortality Review Committee Method: The Gross death rate is determined by calculating deaths within 24hrs of admission into a hospital. This gives an assessment of the emergency services in a hospital.Net death rate is the total number of the deaths occurring after 24hrs of hospital admission. It shows the level of clinical efficiency. However, deaths occurring beyond 48 hrs of admission have to be critically reviewed, to rule out the slightest possibility of preventable deaths. A death rate of 3-4%can be used as an acceptable std for efficiency. C) Random Table Method: In this, case sheets are taken out from the medical record department at random and scrutinized on various parameters, such as complications audit, overstay, investigation & infection audit. D) Scoring Method: A score is worked out for each disease and then selected case sheets of those patients in that disease group are taken out for scoring and evaluation. E) On-the-Spot Method Audit Method: The medical audit committee meets on a particular day in a particular department, based on random selection, and then case sheets are evaluated against set standards.
Harrison suggested five main methods: 1) The variation from the norm in the outcome-sentinel cases, relatively uncommon but very serious situations. The best known and indeed the 1st such audit was the British Confidential Enquiry into material deaths, which has changed medical practice and continues to influence it.
2) Departure from specified outcome criteria-criterion-based audit. Applicable to common conditions, where agreed standards of management or management protocols can be used. 3) Comparison of small groups in the same field applicable at local hospital levels.This concerns the examination, diagnosis and treatment of groups of patients with specific ailments by a general practitioner,& its comparison with the treatment rendered by a specialist under similar situations. (studies have shown that they differ significantly. 4) Surveys-Patient satisfaction surveys are very useful in auditing. 5) Peer review-Such reviews are invariably of mutual benefit for the medical fraternity. The primary idea of peer review is to learn from your mistakes.
Once the quality has been assessed by monitoring, actual or suspected problems should be assessed, and deficiencies detected, with an intent to correct. It must be remembered, that at all points, and satisfactory to high quality care must be praised. Improvement can be achieved through re-education, retraining, facilitation in small groups, or by more active persuasion.
It should be noted that medical audit should not be directed at a person and discussed in an open meeting. The person’s dignity and professional ethics must be taken into consideration while bringing the audit results to his or her notice. One should not fall into the trap of using this as a means of witch hunting. The advantages are many from: The self improvement of the professional,to ensuring a high quality of service to the customer (patient). It provides an opportunity to continuously improve performance, diagnostics ability, treatment and learning in general. The objective of medical audit is an improvement in quality, and the best way to establish it is through an orientation program, creating definite protocols and obtaining support from a strong and willing administration. It is a stimulus to the practice of scientific medicine, and an objective and specific check on the professional tasks performed in the hospital.
For effective implementationAttention should be focused on aspects of care which are either high risk or high volume, or commonly prone to problems, for either patients or the staff. Furthermore, common conditions should be handled first. Finally, medical audit must be kept simple, and it must be ensured that tasks undertaken are achievable and are achieved.
Properly conducted medical audit will result in a demonstrable improvement in the quality of medical care. It is potentially a powerful tool for facilitating improvement. It has been accepted, the ultimate assurance of quality. Klien (1976) said: “Those who use public resources should be accountable to the public for the way in which they dispose of those resources”.
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