Medical Hospital and Clinic Industries

Medical Audit is a planned program which objectively monitors and evaluates the clinical
performance of all practitioners. Identifies opportunities for improvement, and provides
mechanism through which action is taken to make and sustain those improvements.
Medical Audit vs. Clinical Audit
Medical audit is defined as the review of the clinical care of patients provided by the medical
staff only.
Clinical audit is the review of the activity of all aspects of the clinical care of patients by
medical and paramedical staff.
NEED FOR MEDICAL AUDIT
Professional motives- Health care providers can identify their lacunae & deficiencies and make
necessary corrections.
Social motives- To ensure safety of public and protect them from care that is inappropriate,
suboptimal & harmful.
Pragmatic motives- To reduce patient sufferings and avoid the possibility of denial to the patients
of available services; or injury by excessive or inappropriate service.
PURPOSE OF MEDICAL AUDIT
To plan future course of action- it is necessary to obtain baseline information through evaluation
of achievements for comparison purpose with a view to improve the services.
Regulatory in nature- ensures full & effective utilization of staff and facilities available.
Assess the effectiveness of efficiency of health programs & services put into practice.
PURPOSE OF CLINICAL AUDIT
Is to improve the quality of health care services by systematically reviewing the care provided
against set criteria. To do so, there should be a clear understanding of current practice. This
requires:
 clear and consistent definitions
 consistent and reproducible data sources
 An ability to change care delivery if improvement is required.
BACKGROUND OF AUDIT PROCEDURE
Clinical audit is a cyclical process where individuals, teams or services:
 Identify a clinical topic of interest or concern
 Identify sources of appropriate data which will assist in assessing the topic, including
medical records and feedback from senior doctors, other clinicians and consumers

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  Review the data against set criteria and standards
 Identify areas for improvement
 Implement those improvements
 Assess the impact of those improvements.
Audits measure elements of care including structure, processes and potentially outcomes of care.
Clinical audit can provide information about the quality of care provided in a narrowly defined
clinical area (for example, a single disease state or a single presentation).
Clinical audit generally uses clinical level data and when managed by senior doctors has high
levels of acceptability and is viewed as a valuable means of informing doctors about their care
delivery. By contrast, traditional clinical indicators have less acceptability amongst doctors as
their data sources may be non-clinical data sets and because the measures chosen may not have
local clinical applicability.
Professional bodies such as the medical colleges support and encourage their members and
fellows to participate in clinical audit. Participation in clinical audit is mandatory as part of a
continuing professional development (CPD) program for some specialist colleges.
Successful clinical audit requires:
 a clearly defined issue or problem
 an ability to measure clinically relevant elements of care which clearly reflect that
problem
 an ability to apply that measure in a rigorous and consistent way which best reflects
patient care
 an ability to change care processes to drive any subsequent improvement in the chosen
measure
 sufficient resources to ensure that the work can be undertaken appropriately and in a
manner which ensures clinician engagement and support
 Clinical leadership.
PREREQUISITES
1. Hospital operational statistics
a. Hospital resources: Bed compliment, diagnostic and treatment facilities, staff
available.
b. Hospital utilization Rates: Days of care, operations, deliveries, deaths, OPD
investigations, laboratory investigations etc.
c. Admission Data: Information on patients i.e. hospital morbidity statistics, average
length of stay (ALS), operation morbidity, outcome of operation etc.
2. The procedure of collection and tabulation of hospital statistics should be standardized.
3. Primary source of this data is medical records, hence accurate and complete medical
record should be ensured.
4. A well trained Medical Record librarian should be present for carrying out quantitative
analysis.

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 5. Hospital planning and research cell should be established at state level to tabulate and
analyze data, with recommendations for improvement.
AUDIT COMMITTEE
Medical audit committee should consist of hospital consultants, who are committed to Medical
audit. The committee should meet once in a month and submit the report to medical
superintendent (MS) as confidential.
It should be constituted of:
 Senior clinical consultant (Chairman)
 Consultants from concerned clinical department (Members)
 Representative of MS (Member)
 Medical record officer (Member Secretary)
PRINCIPLES OF MEDICAL AUDIT
1. Health authorities and medical staff should define explicitly their respective
responsibilities for the quality of patient care
2. Medical Staff should organize themselves in order to fulfill responsibilities for audit and
for taking action to improve clinical performance.
3. Each hospital and specialty should agree a regular programme of audit in which doctors
in all grades participate
4. The process of audit should be relevant, objective, quantified, repeatable, and able to
effect appropriate change in organization of the service and clinical practice.
5. Clinicians should be provided with the resources for medical audit
6. The process and outcome of medical audit should be documented
7. Medical audit should be subject to evaluation
FIVE STAGES OF MEDICAL AUDIT
STAGE 1
PREPARING FOR AUDIT

STAGE 2
SELECTING CRITERIA

STAGE 3
MEASURING PERFORMANCE

STAGE 4
MAKING IMPROVEMENTS

STAGE 5
Using the SUSTAINING IMPROVEMENT
Creating the
methods Environment
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STAGE 1. PREPARING FOR AUDIT
1. Involving users
 The focus of any audit must be those receiving care.
 Users can be genuine collaborators, rather than merely sources of data.
 The concerns of users can be identified from various sources, including:
 Letters containing comments or complaints
 Critical incident reports
 Individual patients’ stories or feedback from focus groups
 Direct observation of care
 Direct conversations
2. Selecting a topic
 Topic should be of concern to service users and has potential to improve service
user ‘outcomes’
 It should be clinical concern (e.g. an acknowledged variation in clinical practice,
high-risk procedures, complex management).
 It should be financially important (either very common and/ or very expensive)
 It should be of local and/or national importance (e.g. a Department of Health
initiative)
 It should be practically viable (e.g. can be measured and you will be able to
implement change or effect the implementation of change)
 There should be new research evidence available on the topic. (e.g. the incidence
of wound infection following hernia repair.)
3. Defining the purpose
The following series of “action verbs” may be useful in defining the aims of an audit.
 To improve,
 To enhance
 To increase
 To change
 To ensure.
EXAMPLES:
 To improve the blood transfusion processes within the trust
 To increase the proportion of patients with hypertension whose blood pressure
is controlled
 To ensure that every infant has access to immunization against diphtheria,
tetanus, pertussis, polio before 6 months of age.
4. Planning
 Involve ALL the people concerned
 Time and resources
 Access the evidence
 Data collection instrument

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  Methodology
 Pilot
 Report and action
 Re-audit
Note: All of these should be documented.
STAGE 2. SELECTION OF CRITERIA
1. Defining criteria
 The audit criteria will provide a statement on what should be happening.
 The standards will set the minimum acceptable performance for these criteria
 The criteria and standards must be:
 Specific-clear, understandable
 Measurable
 Achievable
 Relevant- to aims of the audit
 Theoretically sound, based on current research.
EXAMPLE:
Audit Title- the incidence of wound infection following hernia repair
Criteria- there should be no wound infection in such cases
Standard- 95%, i.e. practice is satisfactory if less than 5% of cases have wound
infection
The basic types and sources of criteria:
 Statistical (empirical) criteria
 Derived from regional or national statistics on length of stay, current
practices, complications, morality.
 They define what physicians presently do in the care of their patients.

 Normative (consensus) criteria

 Represent the judgement of physicians regarding what ought to be done in the
care of patients with certain diagnoses.

 Optimal care (general consensus)

 Concensus of physicians or procedures that constitute good medical care for a
particular condition.

 Essential (critical)
 Consensus of experts in a particular disease or condition on efficacious
treatment and achievable clinical results for that condition.

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  Scientific (validated) criteria
 Clinical research that objectively establishes the efficacy of treatment and its
clinical results in a specific condition.
2. Sources of evidence
Standards maybe based on one, or may combination, of the following:
 National guidance or standards (e.g. Patients’ Charter)
 College or professional organization guidelines
 Laws (e.g. Mental Health Act 1983)
 Current practice (observe and assess current practice)
 Standards used locally by colleagues or competitors (e.g. your neighbouring
trust, ward, etc.).
 Research evidence (from which standards can be developed)
 Literature review of other clinical audits which have published their standards/
results.
 Current knowledge from clinical experience
3. Appraising the evidence
Evidence needs to be evaluated to find out if it is valid, reliable and important
 Aim/Objectives
 Methodology
 Results/ Conclusions
 Applicable to your patient group
STAGE 3. MEASURING LEVEL OF PERFORMANCE
1. Data Collection
 Data can be collected from computer stored data, case notes/medical records, surveys,
questionnaires, interviews, Focus Groups, Prospective recording of specific data.
 Ensure that your data is stored in such a way that it is both secure and conforms to
legal requirements.
2. Data Analysis
 The following approaches may be used in analyzing data
o Descriptive Statistics
o Statistical Tests
o Qualitative Analysis
3. Comparing With Standards Set
 Results may prove most meaningful if following percentages are calculated:
o Percentage of cases meeting each standard.
o Percentage of cases not meeting each standard
o Percentage of cases considered non-applicable
o Percentage of applicable cases meeting each standard
o Percentage of applicable cases not meeting each standard
4. Dissemination Of Feedback Findings
 A combination of passive feedback (written information) and active feedback
(discussion of findings) is preferable when communicating the findings of project.

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STAGE 4. MAKING IMPROVEMENTS
1. Identifying Barriers to Change
 Fear  Culture
 Lack of understanding  Pushing too hard
 Low morale  Consensus not gained
 Poor communication  Culture
 Some methods are:
o Interviews of key staff and/ or users
o Discussion at a team meeting
o Observation of patterns of work
o Identification of the care pathway
o Facilitated team meetings with the use of brain storming or fishbone diagrams
2. Implementing Change
 Develop a clinical audit action plan which specifies:
o what needs to change
o how change could be achieved
o who needs to take these actions
o when the proposed actions will begin
o how these actions will be monitored and by whom
o how and when to assess whether the actions taken have achieved the desired
outcome
STAGE 5. SUSTAINING IMPROVEMENTS
1. Monitoring and Evaluation
 Although improving performance is the primary goal of audit, sustaining that
improvement is also essential.
 If performance targets have not been reached during implementation, modifications to
the plan or additional interventions will be needed.
2. Re-audit
 It is important to go around the clinical audit cycle for a second time in order to
discover whether:
o Agreed actions have occurred
o Changes have achieved the desired improvements
o Standards continue to be met (where no changes were made).
3. Maintaining and Reinforcing Improvement
 Factors that have been identified for maintaining improvements
o Reinforcing or motivating factors built in by the management to support the
continual cycle of quality improvement.
o Strong leadership
o Integration of audit into organization’s wider quality improvement system

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PROBLEM #1:
Annual Report from Enhanced Surveillance for Tuberculosis 2007
The Annual Report from Enhanced Surveillance for Tuberculosis showed that the rate of
completion for tuberculosis treatment was only 40% for a District for all cases notified in 2007.
This was way below the recommended standards recommended by WHO and in the CMO’s TB
action plan.
Hence this audit was done for all the TB cases notified in 2007, in order to find the possible
causes and take measures to improve the completion rates.
Findings & plans for improvement: All the TB notification forms reviewed jointly with the TB
nurse, using the paper reports, and the electronic database reports obtained from the National
Enhanced Surveillance for Tuberculosis (ETS).

It also became apparent that the TB nurse was not supported adequately by the treating clinicians
to submit outcome forms to the HPU in a timely manner.

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Improvement plan: Investigators set up systems within the HPU to monitor submission of
outcome reports, and worked to improve engagement from treating clinicians in outcome
surveillance, as a part of the Hospital Trust’s Clinical Governance Programme.
Results of re-audit: In a re-audit of cases notified in the following calendar year, 26 of the 28
cases had timely submission of outcome reports with 24 cases completing treatment. None of the
patients were lost to follow up, and information on the patients who had moved out was given in
a timely manner to the receiving HPUs.
PROBLEM #2:
AUDITING THE MANAGEMENT OF ACUTE ABDOMINAL PAIN IN THE
SURGICAL UNITS OF BANGOUR GENERAL HOSPITAL, U K- 1977
All patients referred urgently for general surgical problems are seen first in the accident and
emergency department by a registrar or house officer. A six-month survey showed that 10%, of
all new patients presented with acute abdominal pain. The management of these patients was
analysed. Junior staff in the accident department made a correct diagnosis in 57% of the patients
while the most senior clinicians, who saw the patients later, achieved an accuracy of 80 %.
Objective: Increase the proportion of correct diagnoses made by the junior accident and
emergency staff from 57% to 80% (the standard of the senior consultants).
Implementing change: A structured one-page record form was introduced to the accident and
emergency department.
 The form acted as a check list, ensuring that the medical staff recorded all the clinical
features necessary for diagnosing acute abdominal pain and enabling them to see at a
glance this information set out systematically.
 The medical staff were told the results of the analysis of each group of 100 consecutive
forms.
Results: Diagnostic accuracy rose from 57%, to 71%. The proportion of patients admitted fell
from 81 % to 75 %. The proportion who had unnecessary laparotomies fell from 20% to 7%.
Sustaining improvement: Diagnostic guidelines on the more common causes of acute
abdominal pain were issued to the accident and emergency staff. Diagnostic accuracy rose
further to 77% and admissions fell to 66%. And this cycle of the audit continued. Audit started in
hospital and was extended, with the help of a community physician, to cover the practice of a
group of general practitioners with the aim of reducing "unnecessary” referrals.
TYPES OF MEDICAL AUDIT
1. Morbidity Audit
- a simple method of doing medical audit of a group of cases suffering from a disease
category.

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 - findings are matched with predetermined norms and standards of care laid down by
medical staff for this disease category.

2. Audit of Operated Cases

- a group of patients who have been operated for a similar surgical condition are analyzed
under this method.
- the percentage of the preoperative diagnosis which tally with the pathological diagnosis
is an important parameter.
- type of antibiotic used, the no. of postoperative infection, the anesthesia and operation
notes are the points which are investigated in this type of audit.
3. Audit of Obstetric Cases
- involves care during pre-conception, pregnancy, childbirth, and immediately after
delivery.
- done in more or less on the same line as in operated cases
- here percentage of CS, forceps application, MMR, NMR etc. are the important
parameters.
4. Audit of Death Cases in the Hospital (Mortality Review)
- all the deaths which takes place after 48 hrs. of admission to the hospital are normally
subjected to a review by a committee.
- also useful to review the deaths within 48 hrs. (especially death in emergency
department).
5. On-Spot Medical Audit
- in this medical audit team goes to a particular ward and carries out audit when patient is
still in ward and treating medical team is available.
LIMITATIONS
1. Major loopholes are on the part of commitment, participation and seriousness for the audits.
2. Low number of auditors is also concern for hospital audit in this country,
3. The techniques for doing this are imperfect and are not standardized, despite the seemingly
clear-cut methods described in official publications.
4. Being retrospective and dependent entirely on information contained in the record, auditing
can only assess limited aspects of the technical quality care.

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References
UHBristol Clinical Audit Team. (2009). How To: Set an Audit Aim, Objectives & Standards.
Retrieved from http://www.uhbristol.nhs.uk/files/nhs-ubht/4%20How%20to%20Aim
%20Objectives%20and%20Standards%20v3.pdf
Pilania, M. (2015). Medical Audit. Retrieved from
https://www.slideshare.net/ManjuPilania/final-medical-audit
Clinical Audit. (n.d.). Retrieved from
https://www2.health.vic.gov.au/Api/downloadmedia/%7B0BD2778C-141A-46AD-
A354-A0D7FCBDDFC0%7D

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