Clinical Audit:

Gaps Identified and

Improvements
Tsegaye S.
1
Introduction
• The overall goal of CBHI program is to provide financial
protection to the population in the informal sector, while the
main objectives of CBHI are to:
• Improve access to care by substantially reducing out-of-
pocket spending, and providing financial risk protection at
time of seeking health care services;
• Increase utilization of health services;
• Improve quality of care through implementation of clinical
audit, collective bargaining and strategic
purchasing/payment mechanism;
• Mobilize resources for the health sector through collection
of contributions/ and related collections.
….

• In this regard, the evaluation results of the pilot

schemes show that CBHI were successful in meeting
key health systems objectives including improving
financial access to health care services, improving
quality of health care services, and increasing
resource mobilization in the health sector and
strengthening community participation in the
management of health services.
…

• There are also reported cases of moral hazard and

inappropriate practices by providers including lack of
courtesy and mistreating of patients, over
prescription of services such as drugs, diagnostics
and treatments, unnecessarily referring of patients to
private providers and making claims for
reimbursement without backing them up with
necessary and accurate evidences.
…

• such challenges faced during the pilot phase should

not be sustained. There should be mechanisms to
overcome the challenges and reduce the negative
effects. In this regard, one of the interventions that
will help to continuously assess, review and ensure
quality improvement in health service provision is
clinical audit.
 Why Clinical audit?
Clinical effectiveness involves a number of processes, but primary among these
are:
(I) The development or adaptation and use of clinical guidelines to support
evidence-based practice; and
(ii)The use of clinical audit to improve service user care and outcomes
 
The term ‘clinical audit’ is used to describe a process of assessing clinical practice
against standards. Clinical effectiveness involves a number of processes, but
primary among these are:
(I) The development or adaptation and use of clinical guidelines to support
evidence-based practice; and
(ii)The use of clinical audit to improve service user care and outcomes
 
 The term ‘clinical audit’ is used to describe a process of assessing clinical
practice against standards.
Objectives
The objectives of clinical auditing include:
• To verify that services are provided as per the STG and terms of
agreement;
• To prevent intentional and/or unintentional malpractices or errors in
service provisions;
• To minimize unnecessary reimbursement requests by eliminating
fraudulent and mistaken entities from claims of providers;
• To improve patient satisfaction through provision of best possible
health service given the level of the health facility,
• To boost provision of quality health services for CBHI beneficiaries
sustainably
• To generate evidence based information for decision making by CBHI
schemes and health facilities and
• To strengthen partnership between the scheme and the health
facilities.
Areas of good practice

• Staff motivation to learn and improvement

• Documenting prescriptions of CBHI members
separately
Areas for Improvement
OPD
• Incomplete/improper clericals
• No lab request for those in need
• Laboratory result was not attached with the card
• Summary sheet was not properly filled
• Basic patient information was not filled on patient form
• Treatment and diagnosis are incompatible according to STG (E.g. Rx – IP Dx -
BBL)
• Name and signature of the physician were not written even once
• Unnecessary referral(E.g. Referral for Trachoma and HGB result 11 without giving
any primary care)
• Sloppy handwriting
• Prescribing error(e.g. Amoxa 2 pac)
• Unnecessary laboratory request (e.g. stool for chest pain)
• Drug prescribed on patient card is different from that on the prescription
…
PHARMACY
• Some of the sample prescriptions could not be found for the audit
• Failing to fill complete information on the prescription paper (e.g. Diagnosis, name and
signature of the physician...)
• Failure to correct/return incorrect dosage
• Timely report of stock out drugs was not prepared
• Not updating the drug list to the physicians in a timely manner
• Some drugs were substituted by the pharmacist/ without correcting on the card

Laboratory
• Absence of relevant data for auditing
• Most of the laboratory results were not attached to the patient card but result recorded
Miscellaneous
• Name, sex and CBHI membership code error on the SUR
• Too many lost cards for the clinical audit
• There have been summation error on SUR
100%

90%

80%

70%

60%

1st audit Compliance

50% 2nd audit Compliance
3rd audit Compliance

40%

30%

20%

10%

0%
Mind P
lay
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DRUG USE & AVAILABILITY AS
SESSMENT

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