ROLE OF

MEDICAL AUDIT IN HEALTH CARE EVALUATION

By- Dr. Dharmendra Gahwai (PG

Student) Guided by- Dr. Y.D. BADGAIYAN Prof. and Head Dept. of Community Medicine CIMS , Bilaspur (CG)

BACKGROUND

•People learn the best when they are helped to define their own problems and

•When they accept their strength and weakness, decide a course of action and evaluate the consequences of their decisions.

•Medical Audit is planned programme which objectively monitors and evaluates the clinical performance of all practitioners.

•It identifies opportunity for improvements and provide mechanism through which action is taken to make and sustain those improvements.

Initially the quality assessment techniques were-

•Performance appraisal.•Statistical quality control. •Quality assurance •Continuous quality assurance and•Continuous quality improvements.

Now the specialties are -

•Total quality management(TQM).•Just in time (JIT) and •Zero deficit .

•The concept of quality assurance has been replaced by

Medical Audit.

DEFINITION

•Medical Audit is defined as “the evaluation of medical care in retrospect through analysis of medical records.”

• Medical Audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change.

‘Principles for Best Practice in Clinical Audit’ the National Institute for Clinical Excellence (2002)

•Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria.

•Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery.

‘Principles for Best Practice in Clinical Audit’ the National Institute for Clinical Excellence (2002)

•Input for Health Care facilities are men, material , methodology , means , machinery and technology.

•They all work towards one objective – how best we can provide quality patient care.

• Output of hospital is patient care.

• Patient care is intangible and therefore does not liable itself to measurement.

• In measurement of any output the factors to be considered quantity, quality and consumer (patient)satisfaction .

•Patient satisfaction is subjective.

Why Medical Audit ?

•Mac Eachern stated that -

“financial deficiencies can eventually be met but medical deficiencies may cost lives and lost of health which can never be retrieved”.

Why Medical audit?•To ensure the best possible care for

patients.

•To ensure clinical practice is evidence-based.

•Audit is an integral part of Clinical Governance.

•Assist with the implementation of national initiatives .

•To improve working between multi-disciplinary groups.

Why Medical Audit ?

•1. Professional motive – Health care provider can identify their lacunae and deficiencies and make necessary corrections.

•2. Social Motive – To ensure safety of public and protect them from inappropriate , suboptimal and harmful medical care.

•3. Pragmatic motive – To reduce sufferings of patient.

What can be audited?• Structure – The resources and personnel

available, e.g. Investigation facility and availability of doctors.

• Process – Amount and type of activities of clinical care, e.g. annual review for diabetes.

• Outcome – Result of an intervention, e.g. pain relief, patient satisfaction.

PHASES OF MEDICAL AUDIT

•1. MEDICAL ACCOUNTING – is providing adequate medical records of performance which is basis for analysis.

•2.ANALYSIS – actual analysis of recorded data in the clinical records and field reports pertaining to the professional work of the hospital.

QUALITY CYCLE

Identify problems

Identify barrier

Correct the problem

Prevent future

problem

EVALUATION OF QUALITY OF CARE•It comprises three things –•A. Quality of Technical Care.•B. Quality of Art of Care.•C. Administrative support enabling doctors to practice ‘a’ and ‘b’.

•Technical Care can be assessed by adequacy of diagnostic and therapeutic processes.

•Art of Care – manner and behaviour of provider in delivering health care services.

•Administrative support - planning , organizing and directing all resources for patient care to maximise productivity towards better patient care based on evaluation report.

Pre-requisites for Medical Audit• 1. Hospital Operational Statistics.(a) Hospital Resources. bed facility, diagnostic facility, treatment facility.(b) Hospital Utilization Rates. OPD, Days of care, operations, deliveries and

deaths.(c) Admission Data - Hospital morbidity statistics. - Average Length of Stay(ALS) - Operation Morbidity. - Outcome of operation.

Pre-requisites for Medical Audit

2.Standardized hospital statistics collection and tabulation.

3.Medical Record should be accurate and complete.

4.Medical record librarian.5. Medical audit committee .6.Hospital Planning and Research cell

at State level.

METHODOLOGY FOR MEDICAL AUDIT

METHODOLOGY

1.Indirect method - Structure factors

2.Direct method - Process and Outcome factors.

• STRUCTURE FACTORS•Measurement concern with physical

facility, staff and equipments.

•Men, material and machine.

•PROCESS FACTORS•It means the ‘way’ a patient is move

through a medical care system.•The process criteria can be evaluated by

the outcome of procedures like – no. of patient cured, infection rates , no. of bed sores , and patient dissatisfaction.

Medical Audit Cycle

Action Planning

Audit

STAGES OF MEDICAL AUDIT

•1. Criteria development.•2. Selection of cases within diagnosis.•3. Work sheet preparation.•4. Case evaluation.•5. Tabulation of evaluation.•6. Presentation of reports.

STAGES OF MEDICAL AUDIT

1.Criteria Development

•The audit committee should choose the diagnosis to be studied.

•Once diagnosis have been selected the criteria are developed.

- Indications for admission- Hospital services recommended for optimal care- Range of length of stay & indications for

discharge- Complications or additional diagnoses

2.Selection of Cases within diagnosis.

•It is necessary to enough cases to be evaluated in each selected diagnosis to enable the committee to speak with assurance.

•When sample is used the sampling method and interval should be explained.

3.Worksheet Preparation

•A standard form or worksheet for each diagnosis is designed.

•On these sheets recorded pertinent data taken from the patients medical record.

• Variables: ( with structured sub variables)▫Basic data▫ Indication for admission▫ Initial diagnosis▫Diagnosis agreement▫History: each relevant history▫Physical examination▫Lab Tests▫Treatment▫Nursing care▫Complications▫Mortality/Discharge

4. Case Evaluation

•Once worksheets are completed and the charts are available the evaluation follows .

•It is desirable to have physicians make the final evaluation regarding effectiveness of hospital stay and quality of medical care.

•All members of medical staff regardless of speciality to be involved in evaluation.

• A group of five clinicians is considered optimum by Payne.

•Evaluation report includes –

•Admission: appropriate/ inappropriate

•Length of stay: appropriate/ inappropriate

•Hospital services: Adequate/inadequate•Comments.

5.Tabulation of Evaluation

•All pertinent information from the worksheets should be compiled in tabular form.

•Table showing relationships among all variables should be drawn.

6. Presentation of Reports

•This may be done in form of written or oral in front of

• - executive committee•- to entire staff or • - to department primarily concerned.

TYPES OF MEDICAL AUDIT

TYPES OF MEDICAL AUDIT

•Morbidity Audit•Mortality Audit•On spot audit•Statistical Audit.

Morbidity Audit

•Retrospective study of medical records for the particular disease.

•Objectives are -

•To identify measure for adequate patient care practices for particular disease.

•To develop norms for adequate medical care for particular disease.

Mortality Audit (Death Audit)

•Review a case of death within 48 hours of death .

•The case sheet should be examined for quantitative as well as qualitative adequacy.

•The diagnosis, investigation and treatment should be analysed and related with acceptable standard.

•The case are then discussed with committee and inadequacy and bottleneck are communicated to the officer concerned.

On-Spot Audit

•In this method medical audit team goes to a particular ward and carries out audit when patient is still in ward and treating medical team is present.

Statistical Audit

•Medical record data should be prepared ward wise , unit wise or monthly basis.

•The audit committee examines this statistical data and gross deviation from the accepted standards is further investigated.

•Following data may be used –•1. Average length of stay.•2.Bed occupancy rate.•3.Bed turn over rate.•4.Gross and Net death rate.•5.Infection Rate.•6.Complication rate.•7.Consultation rate.

Medical Audit Committee

•Medical Audit Committee in hospital consist of -

•Chairmen- Director/Principal

•Member Secretary - Medical Superintendent

•Members - - Representatives from hospital administration, clinical departments and nursing.

•The function of Medical Audit and quality assurance committee shall be coordination, information , planning search for expertise and follow up.

ROLE OF HOSPITAL ADMINISTRATOR IN MEDICAL AUDIT•1.To facilitate and provide good working

environment.•2.To provide physical facility and

resources.•3.To motivate medical care provider .•4.Patient satisfaction survey to reveal

grey areas.•5.To frame clear cut objectives and

policies.•6.To conduct exit interview and make

changes as suggested.

CONCLUSION

•Patient care includes elements that may be examined objectively or subjectively.

•The objective elements can be measured by statistical documentation and analysis.

•While subjective element require qualitative judgment through clinical evaluation.

•Continuous evaluation provides stimulation for improvements of clinical service, professional education , hospital administration and better patient care.

•Medical and death audit when practiced together can go long way in improving the quality of patient care which at present is far below the expectation of community.

THANK YOU