Introduction

The measuring of work “Audit” as per the Shorter Oxford English Dictionary is:

1. A hearing, a judicial hearing of complaints, a judicial examination

2. Official examination of accounts with verification by reference to witness and vouchers

3. To make an official systematic examination of accounts

Literally, by audit we mean the systematic examination of accounts, all of us know that financial audit is being conducted regularly in all the departments where financial transactions are in vogue. The sole purpose of the financial audit is to examine whether the amount sanctioned was properly spent without any misappropriation or embezzlement. The documents used for financial audit are account books, invoices, cash receipts, vouchers, other relevant inventories, etc. Similarly, the medical audit, which has been defined as an objective method for applying a yard stick to the quality of professional performances, is a method of evaluating the quality of medical care given to the patient, it serves as a tool to enable the hospital administrator and medical staff to uncover inefficient service and point the way to the evaluation of standards in the hospital.

Most of the hospitals in India have a long way to go to conduct the medical audit. However, the same is carried in some of major hospitals by way of conducting clinical societies, clinic-pathological conferences, etc. in Western and European counties, the medical audit is being carried out since the year 1918 in order to promote efficiency.

 

Material for Medical Audit

1. Medical records of patients: Patient’s record maintained by the medical record department which forms a very important document of hospital can be used for evaluating the quality of medical care given to the patient. The medical record has been defined by Dr Malcom MacEachern, known as the father of medical record science, as “Clear, concise and accurate history of the patient’s life and illness, written from the medical point of view, and in its true form is a complete compilation of scientific data derived from many sources, coordinated into an orderly documented by the medical record department and finally filed away for various uses, personal and impersonal”

Dr JR Mc Gibony has defined medical record as a “clinical, scientific, administrative and legal document” “relating to patient care in which is recorded sufficient data, written in sequence of events to justify the diagnosis and warrant the treatment and end results. Medical records present a complete picture of the care given by the physician and other staff in the hospital, therefore, the medical record can be used in measuring the medical care rendered by the hospital and its medical, paramedical and nursing staff. 

2. Other factors contributing to the quality of medical work: It is not enough to throw the whole blame on personnel dealing directly with the patients. There are certain related conditions which may contribute for good or bad results. Therefore, the following related conditions have to be taken into consideration:

a. Proper administration of the hospital

b. Availability of proper facilities

c. Availability of ancillary services required by me doctors in the better patient care

d. Trained and competent personnel and personnel policies

e. Proper coordination and cooperation of services

f. Proper supervision of patient care

3. The following factors also have to be considered if the objectives of medical audit are to be accomplished:

1. The death rate

2. The infection rate

3. Unnecessary and incompetent surgery

4. Number of patients leaving the hospital against medical advice aria otherwise, etc

5. Consultations

6. Elective and emergency cases admitted

7. The average bed occupancy

8. The average length of stay

9. Number of unimproved cases

10. Autopsy rate

11. Comparative study of work load with number of staff

12. Comparison of yearly admission

 

Methods of Medical Auditing

There are two phases of medical auditing. First phase includes the quantitative aspect by way of providing adequate records of performance as a basis of analysis.

The second phase of medical audit is the qualitative aspect, that is, actual analysis of recorded data in the clinical records, the filled reports pertaining to the professional work of the hospital and other related information. 

The auditing of quantitative and qualitative analysis can be performed by two ways:

1. Internal audit

2. External audit

1. Internal audit

The qualitative aspects of medical auditing can be done by the staff of medical records department. All the records of patients discharged can be collected daily and arranged in a standard chronological order, then the deficiencies of each discharged record is listed in the deficiency slip. This is to enable the doctors to complete during the weekly doctor’s conference (weekly chart review) at the doctor’s conference room in the medical records department.

The qualitative aspects of medical auditing can be done only by the medical personnel who are specialized in the field. Moreover, this check is made time-to-time and day-to-day by the medical staff while carrying out the treatment to the hospitalized patients.

To have a counter check, the medical officers of other unit belonging to the same service can be asked to verify the papers of patient records and give their opinion, whether the treatment carried out was consistent with complaints, diagnosis of patient or not. If they differ, they submit their remarks to the treating doctor. Periodical counter checking of different units of same service is possible only when the heads of various units agree to cooperate in achieving the object of rendering best possible available medical care to patient.

2. External audit

External audit denotes the work of the treating doctor and is done by the members other than the treating team of doctors. This is in addition to internal audit. The following are some of the ways for conducting external audit:

a. Hospital administrator with the assistance of few selected clinicians can undertake the medical audit work by conducting monthly medical statistical meeting in the 1st or 2nd week to discuss the hospital statistics for the previous month including death, unimproved and interesting cases. For this all the medical staff of clinical departments, the senior representatives from the paraclinical department, nursing superintendent and the medical records officer should be asked to attend the meeting. In the course of discussion, the hospital administrator selects cases for critical examination by the clinicians specially selected for the purpose. This random check every month by the clinicians and their periodical report to the administrators and clinicians keeps a check on clinician’s work.

b. Medical audit committee can be formed in each hospital with five to ten physicians/surgeons of good judgement, frank, fearless and without prejudices and well-skilled in their fields selected from major clinical services.

c. The director of medical and health services can select few specialized physician/surgeons for the purpose. These specialists make periodical visits to the hospitals to examine the professional work and make a confidential report to the medical superintendent or director of medical and health services as the case maybe.

 

Medical Audit Sheet

The medical auditors have to design a medical audit sheet to record the observations of the auditors. In the course of verifying the medical records, the auditors will pay attention to detect possible errors of diagnosis, treatment, judgement or technique. Cases for study can be classified as major, minor, intermediate or elective, emergency, routine, etc. Besides this, other factors contributing to the quality of medical care have to be noted down which are considered as essential to the success of a system of medical auditing. The medical auditors will always have to observe the following:

1. Constructive criticism with no spirit of fault finding

2. Honesty and fearlessness in dealing with errors

3. Observance of confidential nature of all records kept under the system of medical auditing

This worksheet used during the medical audit should neither become a permanent part of the medical record, nor should it be preserved. This does not mean the errors are ignored. Measures should be taken to prevent their repetition.

 

Benefits of Medical Audits

Medical audits if properly conducted will highly benefit the patient, the doctor, the hospital and the entire community. 

 

Conclusion

The medical audit should function besides general medical staff meetings, departmental staff meetings and clinico-pathological meetings. The group spirit and scientific attitude demonstrated in these will enhance the role of the physician and promote the safe and proficient care of the hospitalized patient.

Even though the quality of medical care of a hospital is measured by its medical records, the medical record department is an essential department of the hospital, but in developing countries, we find so many large and small institutions including teaching hospitals are running without properly organized medical records departments. Unless, well-organized medical record departments are established at least in all teaching hospitals, the question of carrying out a medical audit does not arise. The first and foremost thing is to see that all the major hospitals give importance in establishing and organizing the medical records department for scientific maintaining of patient records. The medical staff of all hospitals should adopt minimum standards for their medical records, and require each medical staff members, to keep his record upto standard and should audit its work. It is not enough to state that good results have been obtained , the organized medical staff should also justify its work in terms of morbidity and mortality and show that its success is consistent with general average while failures were inevitable.

At present, we may postpone auditing of medical records, but we cannot do it indefinitely as the patient or his relative may take an action for malpractice which may be brought against hospital and its employees in a civil or criminal court. The danger is not so actually felt in under—privileged countries at this time but with a man beginning to realize his right and privileges not before long, that things may create problems to medical, nursing, paramedical and other staff. The hospital medical record which forms a part and parcel of the hospital property is used as a legal document to detect negligence and the treatments rendered were or were not adequate and proper.