MEDICAL AUDIT

Dr. ANM Shamsul Islam

Program Coordinator - MPH
Associate Professor
Public Health & Hospital Administration
NIPSOM
 Medical Audit
• 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
• Medical Audit is a planned program
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.
 Medical Audit
Initially the quality assessment techniques
were -
• Performance Appraisal
• Statistical Quality Control
• Quality Assurance
• Continuous Quality Assurance and
• Continuous Quality Improvements
 Medical Audit
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been replaced by Medical Audit.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 of Medical Audit
• Medical Audit is defined as “the
evaluation of medical care in retrospect
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)
 Definition of Medical Audit
• 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 in Health Care Facility
• Input for Health Care facilities are men,
money, material, methodology, market,
media, method, moment, merit,
moment, machinery.

• They all work towards one objective –

how best we can provide quality patient
care.
 Output in Health Care Facility
• 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 patients
 What can be Audited
• Structure (Input-9M) – The resources
and personnel available e.g. Investigation
facilities 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

Prevent future Identify

problem problems

Correct the Identify

problem barrier
 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’
 Evaluation of Quality of Care
• Technical Care - can be assessed by
adequacy of diagnostic and therapeutic
processes
• Art of Care - manner and behavior of
providers in delivering health care services
• Administrative support - planning,
organizing and directing all resources for
patient care to maximize productivity
towards better patient care based on
evaluation report
 Pre-Requisites for Medical Audit
1. Hospital Operational Statistics -
(a) Hospital Resources
bed, diagnostic, treatment facilities
(b) Hospital Utilization Rates
OPD, Days of care, operations, deliveries & 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 of Medical Audit

1. Indirect method -
Structure factors

2. Direct method -
Process and Outcome factors
 Methodology of Medical Audit
Structure Factors:
• Measurement concern with physical facility,
staffs 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
8. Re- Select
audit topic

7. 2. Agree
Implement standards of
change Action Planning best practice

Audit

6. Make 3. Define
recommendations methodology

4. Pilot
5. Analysis and
and data
Reporting
collection
 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.
 3. Worksheet Preparation
• Variables: ( with structured sub variables)
• Basic data
• Indication for admission
• Initial diagnosis
• Diagnosis agreement
• History: each relevant history
• Physical examination
• Laboratory 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

• 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 analyzed and
related with acceptable standard.
 Mortality Audit (Death Audit)
• The case are then discussed with
committee and inadequacy and bottle-
neck 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.
 Statistical Audit
Following data may be used –
1. Average Length of Stay (ALS)
2. Bed Occupancy Rate (BOR)
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/surgery
specialist
• Members - Representatives from hospital
administration, major clinical departments
and nursing
Function of Medical Audit Committee

• 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.
 Conclusion
• 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