Introduction

Medical audit also called peer review or clinical audit is defined as evaluation of medical care in retrospect through review and analysis of medical records. It is an excellent tool for evaluation of the quality of services (including the quality of records) being provided and the corrective actions required to be taken.

The program of medical audit is an ongoing activity involving study of medical records of the patients aimed at assessing the quality of care given to the patients as well as the quality of records generated. Since it is based on the study of records, the outcome of study depends a lot on the quality of records.

 

Objectives

1. To improve the quality of records generated.
2. To improve the quality of patient caret
3. To stimulate the practice of scientific medicine.
4. To eliminate the substandard practices.

 

Quality Management in Hospira/FUNCTIONS

To review the medical records of the patients (after discharge/death) to evaluate all aspects of patient management including the case history, the investigations ordered and their justification, the dialysis, the management  plan (medical treatment/procedures), the results of treatment, period of  hospitalization, the complications if any, their causes and the outcome of trex<‘lt.

1. TO evaluate the content and quality of medical records generated.
2. To identify the deviations, if any, from the standard operating protocols/ procedures.
3. To analyse the deviations with a view to establish the causes.
4. To comment on the effectiveness of the patient management system on the basis of a general pattern of outcome.
5. To the corrective measures.

Outcome of Successful Medical Audit Program

1. High quality medical records, complete, correct and a; per the prescribed format.
2. accountability of the staff.
3. Reduction in the incidence of avoidable complications, morbidity and mortality.
4. Improved quality of patient care.

 

Requirements Of A High Quality Medical Audit

The Structural Requirements

The program is carried out through a Medical (Cliniel) Audit Committee constituted for the specific purpose by an administrative order, laying down the terms and conditions, the objectives and the scope of activities. The committee should have a wide representation from all the major specialties and may be chaired by the senior most specialist in the group. Medical records officer (ex-officio) or any other suitable member may be appointed as the member secretary of the committee which should be reporting directly to the MS.

The role of the medical audit committee is to ascertain from the scrutiny of records whether the patient care being given is as per the acceptable standard/protocols or not, and if not, what are the non conformities?  What are their causes? Are they significant/justified ? what remedial  actions need to be taken to prevent their recurrence and improve the quality of care. This committee should not become a court of inquiry trying  to pinpoint faults for victimization.

Process Of Medical Audit

Process means the manner in which the medical audit is carried out and it is immensely important for credibility as well as effectiveness of the program. Process should cover the following essential aspects.

1. Medical audit program must be documented as an integral part of the QMS implemented and all medical/nursing staff must be fully acquainted with the program so that the importance is understood by all and the records are generated as per the standardized formats.

2. The program should have clearly laid down scope and broad guidelines about the system of functioning.

3. Detailed working procedures should be developed and documented by the audit committee.

4. The committee should meet as per a regular schedule, the records of proceedings must be maintained along with the documents studied.

5. The methodology adopted should be scientific, practical and aimed at yielding concrete results in terms of the objectives of the program. It will involve the following steps.

a. Selection of rg4fopics

i. The study topics are selected with a clear aim such as:

ii. Completeness of the records generated as per the standard content format. This may require study of all the records of patients admitted/discharged or randomly selected representative samples. The sample selection should be by established statistical  techniques and unbiased.

iii. It may be research oriented such as evaluating the management of a particular disease or success rate of a particular procedure   (surécünon surgical).

iv. The topic may be problem oriented, including all cases related to a particular problem such as postoperative infection of surgical site, hospital deaths, hospital acquired infections or other complications.

The disease/procedure/problem oriented studies have the advantage that simultaneously the quality of records can also be checked However, the system of indexing of records will have to include the indexing as per diagnosis/surgical procedure as  well.

b. Selection of bbe time frame: Period of the review may be decided so that the sample size is large enough and also the seasonal/other variations do not cause any bias.

c. Deciding the sample size: The sample size may be decided so that it is practically possible, eliminates any bias and lends a desirable level of accuracy and reliability of results. Depending upon the patient load, the sample may include every 3rd, 5th or 10th patient admitted, In case of disease/problem oriented study it may include all cases admittedÆischarged during the period of review.

d. Development of criteria: Criteria for evaluation are of utmost importance. In order to make it a scientific and objective study the criteria selected must be relevant, understandable, measurable, behavioral achievable and directly related to the aim of study. Examples of some of the criteria are given below.

i. Are the records complete (as per the standard content list) ? Are their any deficiencies ?

ii. Was the diagnosis supported by the findings ?

iii. Were all the investigations justified ?

iv. Was the treatment given as per the accepted protocols ?

v. in surgery cases—did the histopathology report confirm the preoperative diagnosis ? Was the autopsy carried out ? Did the report confirm the diagnosis ?

vi. Consultations/referrals, if indicated ?

Was the case within the competence of the treating doctor ?   Negligence, if any ?

1. Was the length of stay within normal range ?
2. Was there any delay at any stage ?
3. Did the final bill overshoot the initial estimate ? If so, what were the reasons ? Was the expenditure justified ?

e. Review and analysis of medical records:

i. Screening of records in the category under review

ii. Data review—Comparison of the information/data in the patients’ charts with the committee criteria and detecting the variations/non conformities if any, For instance, the observed neonatal mortality rate compared to the laid down/standard rate.

iii. Analyzing the variations to evaluate whether they are justified ? If unjustified, to find out whether these are due to individual failure or process/system failure.

iv. If it is due to individual failure, interview the doctor/nurse/ technician concerned for clarifications/explanations required. Referring the case to the department concerned for their views/considered comments.

v. If the non conformity is due to process/system failure, then identify the defective element in the activity/process.

f. Recommendations for corrective action

i. Counselling Of the errant individual ifit is a case of human error

ii. or suitable action if the lapse is of serious nature.

iii. If it is a case of system/process failure then suitable change in the policies and procedures so that the scope of recurrence can be eliminated

6. Proceedings of the Committee

The committee should be meeting at fixed periodicity and as when required. The dates/timings may be fixed so as to facilitate  attendance.

In a particular case if the treating physician happens to be a member of the committee, he may not participate in the process, except when required by the committee for any clarifications.

7. Documentation

a. Proceedings of the committee meetings must be recorded along with the activities carried out, the records studied, the non conformities detected, the causative factors and the remedial measures recommended..

b. Observations (and recommendations) of the committee should be confidential and forwarded to the MS for suitable action. The actions taken by the committee or by the MS, should also be documented.

8. The Medical Records department has to ensure that the records/data required are made available at the date/time fixed.

9. Availability of adequate resources to facilitate data collection. Availability of automated information systems can be an asset.

10. The aspect that is crucial to success of audit program is objectivity, Whether it is the selection of criteria or the analysis of findings, the committee has to guard against subjectivity or bias of any kind, otherwise the purpose is defeated

11. It is important to involve a reasonably large number of doctors to ensure better attendance level, However, it is even more important that the members are selected on the basis of their professional standing,

 

Quality Management in Hospitals

integrity and commitment to improvement of quality of care. They   may be given initial training in the process of audit.

Counseling/other action taken against the persistently errant doctors/ other staff may be kept confidential. However, feedback (without naming the individuals) about the deficiencies in service must be communicated to the staff concerned to stop recurrence of the same mistakö.

Indicators Of Effectiveness Of The Program

1. Improvement in the quality of records generated as assessed from the number of observations by the committee.
2. Drop in the incidence of the problems studied, after implementation  of the corrective measures.
3. Improvement in the quality of patient care as observed from—
4. The decrease in number of obser-vations by the committee
5. Decrease in avoidable complications such as, postoperative surgical site infection death rate, ALS, medication errors.
6. Increase in patient satisfaction rate.

Medical auditing, in spite of its utility, is not in practice in many hospitals  probably because of the fear of exposure of faults as well as reluctance of the doctors to criticize each other. In the process, the hospital remains deprived of a very effective means of improvement.

However, the chances of exposure (of errant physicians) are hardly any, if the proceedings are kept confidential and the members of the audit committee are selected strictly on the basis of professional standing and maturity. The value of Medical (Clinical) Audit, as an instrument of improvement of quålity of care is being gradually realized now as it has been included in the NABH/JCI accreditation standards also.

 

Chapter         

Medical Audit

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 and other relevant inventories, etc. Similarly, the medical audit is defined as an objective method for applying a yard stick to the quality of professional performance. It is a method of evaluating the quality of medical care given to the patient, and 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 the major hospitals by way of conducting clinical societies, clinicopathological conferences, etc. In Western and European countries, the medical audit has been carried out since the year 1918 in order to promote efficiency.

 

History of Medical Audit

Dr Earnest Codman, of Boston enthusiastically emphasized the fact that the professional efficiency of the hospital could not be properly evaluated without good medical records and study of end results. Thus, a monthly reporting of the end results of work done by the physicians in hospital began. This was the forerunner of our present monthly analysis of hospital services and was in reality a very minimal medical audit.

George Gray Ward probably inaugurated the first real medical audit in the United States in 1918 at women’s hospital, New York City. Then in 1929 Thomas R. Ponton presented a plan for professional service accounting and medical audit. This plan with variation, as demanded by changing times and technological progress, has been used quite successfully ever since.

 

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 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 document by the medical record department and finally filed away for uses both personal and impersonal’!

Medical records can also be defined as a “clinical, scientific, administrative and legal document “relating to patient care in which is Medical Audit

3. Unnecessary and incompetent surgery

4. Number of patients leaving the hospital against medical advice and 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 loads with number of staff

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.

12. Other factors contributing to this are two phases of medical auditing. First phase includes the quantitative aspect by way of providing adequate records of performance as a basis for 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 recorded sufficient data, written in sequence METHODS OF MEDICAL AUDITING < of events to justify the diagnosis and warrant/ quality information. The auditing of quantitative and medical work:

It is not enough to throw the whole blame qualitative analysis can be performed by two ways:

1. Internal
2. Comparison of yearly admission.

 

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:

Upper administration of the hospital:

1. Availability of proper facilities
2. Availability of ancillary services required by the doctors in the better patient care
3. Trained and competent personnel and personnel policies
4. Proper coordination and cooperation of services
5. Proper supervision of patient care.

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

 

External.

Internal Audit

The qualitative aspects of medical auditing can be done by the staff of the 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 units 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 the 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 patients.

External Audit

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 may be.

 

Medical Audit Sheet

intermediate or elective, emergency and routine, etc. External audit denotes the work of the treating   Besides this, other factors contributing to the quality

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, judgment or technique. Cases for study can be classified as major, minor, doctor and is done by the members other than the treating team of doctors. This is in addition to internal audits. The following are some of the ways for conducting external audits.

1. Hospital administrators with the assistance of a few selected clinicians can undertake the medical audit work by conducting monthly medical statistical meetings 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,
2. Medical audit committee can be formed in each hospital with five to ten physicians/surgeons of good judgment, frank, fearless and without prejudices, well skilled in their fields selected from major clinical services,
3. The director of medical and health services can select a few specialized physicians/surgeons for the purpose. These specialists make periodical visits medical care has 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:

a. Constructive criticism with no spirit of fault finding

b. Honesty and fearlessness in dealing with errors

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

This work sheet 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 ‘Sill 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 clinicopathological 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 which are operational 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 maintenance of patient records.

The medical staff of all hospitals should adopt minimum standards for the medical records and should audit their work It is not enough to state that good results have been obtained; the organized medical

Medical Audit

staff should also justify their 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 the hospital and its employees in a civil or criminal court. The danger is not much felt in underprivileged countries at this time but with the patient beginning to realize his rights 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 that if treatments rendered were or were not adequate and proper.