MEDICAL AUDIT

CONTENTS

• Definitions

• History

• Need and Purpose

• Prerequisite

• Medical audit committee

• Principles

• Stages

• Types

• Limitations

• Place of medical audit in modern medicine

DEFINITION

Medical Audit is a planned programme

• which objectively monitors and evaluates the clinical

performance of all practitioners,

• which 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.

• By 1994, the term ‘clinical audit’ appeared to have largely

replaced the earlier term ‘medical audit’

HISTORY

HISTORY

• 1750 BC: the 6th king of Babylon, Hammurabi instigated

audits for the clinicians.

• Modern medicine (1853–1855): Florence Nightingale

conducted first clinical audit during the Crimean War. She

applied strict sanitary routine & hygiene standards that

decreased the mortality rates from 40% to 2%.

• 1869–1940: Ernest Codman became known as the first

true medical auditor following his work in 1912 on

monitoring surgical outcomes. Codman's "end result idea"

was to follow every patient's case history after surgery to

identify errors made by individual surgeons on specific

patients.

HISTORY

• A growing requirement for more formal audit in the middle

1980s was accelerated by publication of the Confidential

Enquiry into Perioperative Deaths (CEPOD) in 1987 and

the Government White Paper, entitled ‘Working for

Patients’ in 1989.

• 1961: Report of Mudaliar committee stressed on

encouragement of medical audit in India.

• 1969: Then Health Minister of India Dr Sushila Nayyar

introduced medical audit in India.

• But it became operational only in 2007, after the

establishment of National Accreditation Board for Hospitals

and Healthcare Providers (NABH) in 2005.

NEED & PURPOSE

NEED FOR MEDICAL AUDIT

1. Professional motives- Health care providers can identify

their lacunae & deficiencies and make necessary

corrections.

2. Social motives- To ensure safety of public and protect

them from care that is inappropriate, suboptimal &

harmful.

3. Pragmative 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

1. 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.

2. Regulatory in nature

• ensures full & effective utilisation of staff and facilities

available.

3. Assess the effectiveness of efficiency of health

programmes & services put into practice.

PREREQUISITES FOR MEDICAL AUDIT

PREREQUISITES

1. Hospital operational statistics

a. Hospital resources : Bed compliment, diagnostic and

treatment facilities, staff available.

b. Hospital utilisation 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.

PREREQUISITES

2. The procedure of collection and tabulation of hospital

statistics should be standardised.

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.

5. Hospital planning and research cell should be established

at state level to tabulate and analyse data, with

recommendations for improvement.

MEDICAL AUDIT COMMITTEE

MEDICAL 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 depts Members

• Representative of MS Member

• Medical record officer Member Secy.

PRINCIPLES OF MEDICAL AUDIT

PRINCIPLES

1. Health authorities and medical staff should define

explicitly their respective responsibilities for the quality of

patient care.

2. Medical staff should organise themselves in order to fulfil

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.

PRINCIPLES

4. The process of audit should be relevant, objective,

quantified, repeatable, and able to effect appropriate

change in organisation 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.

STAGES OF MEDICAL AUDIT

FIVE STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

AUDITING THE MANAGEMENT

OF ACUTE ABDOMINAL PAIN IN THE SURGICAL

UNITS OF BANGOUR GENERAL HOSPITAL, U K-

1977

Problem :

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 %.

GRUER R, GUNN A A, RUXTON A M. Medical audit in practice .British Medical_rournal,1977;

1, 957-58

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).

GRUER R, GUNN A A, RUXTON A M. Medical audit in practice .British Medical_rournal,1977;

1, 957-58

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..

STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

STAGE1. PREPARING FOR AUDIT

1. Involving users

2. Selecting a topic

3. Defining the purpose

4. Planning

1. INVOLVING USERS

• The focus of any audit project 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 of 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).

2. SELECTING A TOPIC

• 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

AREA OF MEDICAL AUDIT

1. Indirect: ‘Structure' factors that influence efficiency of

medical care e.g. staff, equipment, physical facilities and

material supplies.

2. Direct:

a) Process: Measures what a provider does to and for a

patient (e.g. ordering ECG for patient with chest pain) It

also means the 'way' a patient is moved through a

medical care systems

b) Out come: reflects what happened to the patient in terms

of palliation, treatment, cure or rehabilitation. It is

expressed primarily as the result of medical treatment vs

patients pre-hospitalisation state of health.

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

3. DEFINING THE PURPOSE

e.g.

• 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 immunisation

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

• Methodology

• Pilot

• Report and action

• Re-audit

All these

should be

documented

STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

STAGE 2. SELECTION OF

CRITERIA

1. Defining criteria

2. Sources of evidence

3. Appraising the evidence

1. DEFINING CRITERIA

• The audit criteria will provide a statement on what should

be happening.

• the standards will set the minimum acceptable

performance for those criteria.

• The criteria and standards must be

• Specific – clear, understandable

• Measurable

• Achievable

• Relevant – to the 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.

1. DEFINING CRITERIA

• The basic types and sources of criteria:

• Statistical (empirical) criteria

• Normative (consensus) criteria

• Optimal care (general consensus)

• Essential (critical)

• Scientific (validated) criteria

STATISTICAL (EMPIRICAL) CRITERIA

• Derived from regional or national statistics on length of

stay, current practices, complications, mortality.

• These are derived from statistics on actual practice.

• They define what physicians presently do in the care of

their patients.

• These statistics may come from the individual hospital's

records or, more commonly, from hospital data abstracting

systems.

NORMATIVE (CONSENSUS) CRITERIA

Represent the judgment of physicians regarding what ought

to be done in the care of patients with certain diagnoses.

1. Optimal care (general consensus):

• Consensus of physicians on procedures that constitute

good medical care for a particular condition.

• They cannot be used to assess the technical quality of

care.

• The fundamental shortcoming of optimal care criteria is

their lack of relationship to outcomes.

NORMATIVE (CONSENSUS) CRITERIA

2. Essential (critical):

• Consensus of experts in a particular disease or condition

on efficacious treatment and achievable clinical results for

that condition.

• Essential criteria apply to almost every patient with a

specified condition because they stipulate elements of care

known to produce the desired clinical results in patients

with that condition.

SCIENTIFIC (VALIDATED) CRITERIA

• Clinical research that objectively establishes the efficacy of

treatment and its clinical results in specific conditions.

• The ideal criteria for an audit are purely scientific criteria

derived from results of randomized clinical trials (RCT).

• Scientific study establishes the degree of efficacy or

effectiveness of drugs, treatments or operations in

reducing mortality, preventing complications or objectively

improving the patient's condition.

• Unfortunately, all this information is not assembled or

published in a form that permits audit committees to pick

out pre-specified "scientific criteria."

2. SOURCES OF EVIDENCE

Standards may be based on one, or any combination, of the

following:

• National guidance or standards (e.g. Patients’ Charter).

• College or professional organisation 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.).

2. SOURCES OF EVIDENCE

• 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

EXAMPLE -WHO CRITERIA FOR CLINICAL AUDIT OF

QUALITY OF HOSPITAL BASED OBSTETRIC CARE IN

DEVELOPING COUNTRIES

Precedence was given to

evidence from RCT>

Studies with less robust

design> Expert opinion

EXAMPLE -ECLAMPSIA

STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

STAGE 3. MEASURING LEVEL OF

PERFORMANCE

1. Data collection

2. Data analysis

3. Comparing with standards set

4. Dissemination of feedback findings

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.

• The careful selection of an appropriate data collection tool

is also important.

• Do not try and collect too many items, keep it simple and

short.

• Always conduct a small pilot study.

• The reliability of data can also be improved by providing

appropriate training in data collection for the person

undertaking this task.

• Ensure that your data is stored in such a way that it is both

secure and conforms to legal requirements.

1. DATA COLLECTION

2. DATA ANALYSIS

• The following approaches may be used in analysing data

descriptive statistics

statistical tests

Qualitative analysis

• When analysing data, it is tried to reach conclusions about

the general pattern of actual practice.

3. COMPARING WITH STANDARDS SET

Results may prove most meaningful if following percentages

are calculated:

• percentage of cases meeting each standard.

• percentage of cases not meeting each standard

• percentage of cases considered non-applicable

• percentage of applicable cases meeting each standard

• percentage of applicable cases not meeting each standard

4. DISSEMINATION OF FEEDBACK FINDINGS

It is important that all of the key stakeholders are made

aware of the findings of the project and are provided with

an opportunity to comment on them.

A combination of passive feedback (written information)

and active feedback (discussion of findings) is preferable

when communicating the findings of project.

STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

STAGE 4. MAKING

IMPROVEMENTS

1. Identifying barriers to change

2. Implementing change

1. IDENTIFYING BARRIERS TO CHANGE

Fear

Lack of understanding

Low morale

Poor communication

Culture

Pushing too hard

Consensus not gained

1. IDENTIFYING BARRIERS TO CHANGE

Some methods are

• Interviews of key staff and/ or users

• Discussion at a team meeting

• Observation of patterns of work

• Identification of the care pathway

• Facilitated team meetings with the use of brain storming or

fishbone diagrams

2.IMPLEMENTING CHANGE

Develop a clinical audit action plan which specifies:

what needs to change

how change could be achieved – what actions need to

take place

who needs to take these actions

when the proposed actions will begin

how these actions will be monitored and by whom

how and when to assess whether the actions taken have

achieved the desired outcome

STAGES

STAGE ONE

Preparing for audit

STAGE TWO

Selecting criteria

STAGE THREE

Measuring performance

STAGE FOUR

Making improvements

STAGE FIVE

Sustaining improvement

Using the

methodsCreating the

environment

STAGE 5. SUSTAINING

IMPROVEMENTS

1. Monitoring and evaluation

2. Re-audit

3. Maintaining and reinforcing improvement

1.MONITORING AND EVALUATION

• Although improving performance is the primary goal of

audit, sustaining that improvement is also essential.

• Only minimum number of essential indicators should be

included in monitoring.

• 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:

• agreed actions have occurred

• changes have achieved the desired improvements – i.e.

closer to set target and, therefore, improvements in service

delivery

• standards continue to be met (where no changes were

made).

3. MAINTAINING AND REINFORCING

IMPROVEMENT

Factors that have been identified for maintaining

improvements

• Reinforcing or motivating factors built in by the

management to support the continual cycle of quality

improvement.

• Strong leadership

• Integration of audit into organisation’s wider quality

improvement system

EXAMPLEProblem :

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.

Audit title :

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).

30 notified cases in 2007

Outcome reports were

submitted for 16 cases

no record of outcome forms for

the other 14 cases

when the report was compiled at the Regional Office using the ETS

database, at 24 months after the initiation of treatment

12 had

completed

treatment

one had died due to

other causes

one had moved out

of area

2 were still on treatment

due to interruptions

caused by side effects

of drugs.

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.

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.

TYPES OF MEDICAL AUDIT

TYPES OF MEDICAL AUDIT

MORBIDITY AUDIT

• A simple method of doing medical audit of a group of cases

suffering from a disease category.

• Findings are matched with predetermined norms and

standards of care laid down by medical staff for this disease

category.

• It is done ward/unit wise.

AUDIT OF OPERATED CASES

• A group of patients who have been operated for a similar

surgical condition are analysed under this method.

• Again a group of surgeons is asked to lay down the

desirable norms and standards.

• Particular emphasis is laid on the pathological reports of

the tissues during operation.

• The percentage of the preoperative diagnosis which tally

with the pathological diagnosis is an important parameter.

• Type of antibiotics used, the no. of postoperative infection,

the anaesthesia and operation notes are the points which

are investigated in this type of audit.

AUDIT OF OBSTETRIC CASES

• Done in more or less on the same line as in operated

cases

• Here percentage of C/S, forceps application, MMR, NMR

etc. are the important parameters.

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)

• Case sheets are examined for quantitative as well as qualitative

adequacies

ON SPOT MEDICAL 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 available.

LIMITATIONS

LIMITATIONS

1. The major loopholes are on the part of commitment,

participation and seriousness for the audits. Audits in

Indian scenario are still more or less considered as an

obligation and are done only to fulfil the requirement of

various accreditation or other external agencies rather

than for the improvement of hospital processes and

quality in actual.

2. Low number of auditors is also a concern for hospital

audit in this country.

LIMITATIONS

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 of care.

PLACE OF MEDICAL AUDIT IN MODERN HEALTHCARE

PLACE OF MEDICAL AUDIT IN

MODERN HEALTHCARE

• Today, due to growing individual income, health has

become a priority for Indians.

• Patients put a lot of value to the quality of healthcare

provided by the hospitals.

• In recent years, with the mushrooming of hospitals,

patients have an array of hospitals to choose from.

• So the competition among the hospitals to maintain their

standards and improve them as and when required has

become stiff.

• In addition, number of malpractice and negligence suits

against the providers of healthcare are increasing.

PLACE OF MEDICAL AUDIT IN

MODERN HEALTHCARE

• This also puts additional pressure on organizations and

practicing physicians to evaluate the quality of care

provided.

• Hospitals have to create patient care and safety impact,

the moment a patient is admitted to the hospital through

processes and infrastructure.

• The process of audit ensures consistency in delivery of

clinical and non-clinical services; it also addresses the

habit of continual improvement

PLACE OF MEDICAL AUDIT IN

MODERN HEALTHCARE

• Medical audit is far more important to a hospital than

financial audit. Financial deficits can be met eventually but

medical deficiencies can cost lives, or loss of health

thereby resulting in unwanted agony.

• Medical audit has just begun to gain momentum in India

and needs acceptability by the hospital systems and

medical fraternity as an improvement initiative rather than

a fault finding mechanism.

REFERENCES

• NHS, CHI, Royal College of Nursing. Principles for Best Practice in Clinical Audit. University of Leicester Radcliffe Medical Press; 2002. p.976.

• Sharma Y, Mahajan P. Role of Medical Audit in health Care Evaluation. JK science.1999;1(4).193-6.

• Clinical Audit And Case Review: Guidance from the Faculty of Public Health.UK. 2012

• Ashwini NS, Vemanna NS, Vemanna P. The Basics in Research Methodology: The Clinical Audit. JNMR 2011;5(3).679-82.

• Sanazarop J.Medical Audit, Continuing Medical Education and Quality Assurance. West. J. Med1976; 125.241-52,

• Undertaking a clinical audit project: a step-by-step guide e book chapter 2 [ cited on dec. 2012]

available from www.rcpsych.ac.uk/pdf/clinauditChap2.pdf

THANK YOU