WHAT IS AUDITA systematic and critical appraisal of the planning,delivery and evaluation of service/s in terms ofefficiency, effectiveness and quality, within givenresources.Evaluation of data, documents and resources tocheck performance of systems if meets specifiedstandards.Audit in the wider sense is simply a tool to find out: -how you do now; -what you have done in the past, -what is wish to be done in the future for remedy.
WHY AUDIT•Maintain participant and staff safety.•Maintain data quality .•Protect reputation of staff, organiser and hospital•Protect current and future funding•Improve quality.•Useful for clinical improvement•Encourages teamwork•Improves patient care•Financial benefits•Contractually an obligation as per government policy•Becoming essential for meeting litigations under CPA•It does not involve experiments or research
TYPES OF AUDITAUDIT MAY BE INTERNAL OR EXTERNAL MANAGERIAL/ ORGANISATIONAL MEDICAL AND FINANCIAL CLINICAL
DIFFERENT AUDITSDistinctions have been drawn between differenttypes of audit in terms of the focus of theactivity and the personnel involved. Thus: * medical audit involves the review of activitiesinitiated directly by doctors * clinical audit covers all aspects of clinical careincluding that provided by nursing andparamedical staff * organisational audit refers to investigation ofaspects of practice such as appointmentssystems, policies, practices, standards which areregarded as primarily administrative functions.
METHODS USED IN AUDIT Direct observation Checklists Documentation/records audit Questionnaires Interviews Clinical Case review
WHAT IS MEDICAL AUDIT"Medical Audit" is a planned review programme whichobjectively monitors and evaluates the clinical performance of allpractitioners, records by qualified professional personnel toidentify, examine,or verify the performance using establishedcriteria.There by identifies opportunities for improvement, andsuggests mechanism through which action is taken to make andsustain those improvements.The systematic critical analysis of the quality of medical care,including the procedures used for diagnosis and treatment, theuse of resources and the resulting outcome and quality of life forthe patientClinical Audit A quality improvement process that seeks to improve patientcare and outcomes through systematic review of care of health care teamagainst explicit criteria and the implementation of change.
TYPES OF CLINICAL AUDIT CLINICAL AUDIT CONCURRENT RETROSPECTIVE AUDIT AUDITCare is evaluated at care is evaluated after itthe time it is taking has been completedplace through records.
NEED FOR MEDICAL AUDIT1. For Professional•Health care providers can identify their lacunae &deficiencies and make necessary corrections.2. For society•To ensure safety of public and protect them fromcare that is inappropriate, suboptimal & harmful.3. For health promotion•To reduce patient sufferings and avoid thepossibility of denial to the patients of availableservices or injury by excessive or inappropriateservice.
PURPOSE OF CLINICAL AUDIT1. To plan future course of action, it is necessary to obtain baseline information through evaluation of achievements2. For comparison purpose with a view to improve the services.3. It is regulatory in nature ensuring full & effective utilisation of staff and facilities available.4. Assess the effectiveness and efficiency of health programs & services put into practice.5. Describe and measure present performance6. Help developing explicit standards7. Suggests what needs to be changed8. Help Mobilise resources for change9. Reviews the past and modify the present process
PRE-REQUISITE FOR CLINICAL AUDIT CLINICAL AUDITMEDICAL AUDIT WELL ORGANIZED COMMITTEE MEDICAL RECORD HOSPITAL STATISTICS
1.MEDICAL AUDIT COMMITTEE Hospital Administration - Chairman Officer In charge MRD - Member Secretary Heads of Surgery, Medicine, Paed, Gynae, Pathology, Radiology, Casualty, Anaes, - Members Nursing Supdt.-The committee to meet once a month on fixed day.-Preparation of Agenda and records by MemberSecretary.-Discussions are kept secret.-The important findings are communicated to concerndepartment to take remedial action.
2. MEDICAL RECORD-All the junior staff (Residents) to be trained andretrained how to fill up the medical records.-All the medical records must be complete on allaspects before sending to record department.-Records to be properly tied up, coded and indexedmonth wise/ disease wise for easy retrieval.-A complete and correct medical record is the backbone of medical audit.3. Hospital operational statistics(a) Hospital resources : Bed compliment, diagnostic and treatmentfacilities, staff available.(b) Hospital utilisation Rates : Days of care, operations, deliveries, deaths,OPO attendance, laboratory investigations, bed turn over rate etc.(c) Admission Data: Information on patients i.e. Hospital morbidity andmortality statistics, average length of stay, Hosp. infection rate
SIX STAGES OF CLINICAL AUDIT STAGE –I PREPARING FOR AUDIT STAGE –II SELECTING CRITERIA USING METHODS STAGE –III CREATING MEASURING PERFORMANCE ENVIRONMENT STAGE –IV MAKING IMPROVEMENT STAGE –V SUSTAINING IMPROVEMENT STAGE-VI RE AUDIT
STAGE 1: PREPARING FOR AUDIT USERS INFORMATION PLANNING SELECTING A AUDIT TOPIC DEFINING THE PRIORITISE PURPOSE AUDIT
1. USERS INFORMATIONThe concerns of users can be identified fromvarious sources, including:-Letters containing comments or complaints-Critical incident reports-Individual patients’ stories or feedback fromfocus groups-Direct observation of care-Direct conversations-genuine collaborators-sources of data
2. SELECTING A TOPIC-starting point-careful thought and planning- There seems little point in trying to audita rare condition, with a medicalintervention with an insignificant outcome-Try to select topics directly influencingquality of care
3. MEASURE FOR PRIORITISEIs the topic concerned is of high cost, or risk tostaff or users?Is there evidence of a serious quality problem? ( for example patient complaints or high infectionrates?)Is there a potential for deviating from or pertinentto national policy initiatives?(for example systematic reviews or national clinicalguidelines? )Is the topic a priority for the organisation?Is good data is available to compare standards?
4. DEFINING THE PURPOSE-purpose must be established before appropriatemethods for audit can be considered.-Once topic selected, purpose defined then suitableaudit method can be chosen.-The following objectives may be useful in definingthe aims of an audit •to improve the quality •to enhance performance •to increase efficiency •to change procedure •to ensure patient satisfaction •to reduce cost
5. PLANNING AUDITInvolve ALL the people concern. Fix time and Plan resourcesAccess the evidence/dataMethodology to be followed for data collectionPilot studyAudit Report for ActionRe-auditAll activities should be documented.
STAGE 2: SELECTION OF CRITERIA APPRAISING DEFINING THE CRITERIA EVIDENCE SOURCES OF EVIDENCE
1. DEFINITION OF CRITERIA-Which area:--an individual, a team, or an organisation-This can include assessment of the processand/or outcome of care-The choice depends on the topic andobjectives of the audit.-They should relate to important aspects ofcare and be measurable.
2. SOURCES OF EVIDENCESystematic methods should be used• Good-quality data• Reviews of the past audit• Previously used criteria for same purpose• Measurement of outcome in the past• Need to develop new criteria
3. APPRAISING THE EVIDENCEEvidence needs to be evaluated tofind out if it is valid, reliable andimportant. Meeting Aim /objectivesStudy Methodology Past Results /conclusionsExtent of Applicability to your presentstudyLikely Bias/ causes for concern
STAGE 3: MEASURING LEVEL OF PERFORMANCE HANDLING DATA METHODS OF COLLECTION PLANNING DATA COLLECTION
1. PLANNING DATA COLLECTION -The data collected are to be precise -Essential data -Completed data - Adequate data -User group to be studied -Example: Immunisation status of pregnant women
2. METHODS OF DATA COLLECTION•Do not try and collect too many items, keep it simple andshort, relevant to present study.•Computer stored data, Case notes/Medical Records,•Local Surveys through Questionnaires, InterviewsFocus Groups,•Prospective recording of specific data and compilation- How will this be done to get required information-Compare performance against the criteria-Keep focused on the objective of the audit3. Handling data:Ethical implications of decrecy and their responsibilitiesunder the Data Protection Act (1998) when collecting dataand presenting results to be kept in mind.
STAGE 4: MAKING IMPROVEMENTS MAKING IMPROVEMENTS CHANGE BY IDENTIFY REMOVE BARRIERS BARRIER
1. IDENTIFYING BARRIERS TO CHANGE - Fear - Lack of understanding - Low morale - Poor communication - Individual Culture - Doubt of outcome - Consensus not gained
2. IMPLEMENTING CHANGEsystematic approach:•identification of local barriers to change•change culture•Provide support for teamwork•use of a variety of specific methods likedelegation and accountability
1. MONITORING AND EVALUATION:systematic approach to changing professional practiceshould include plans to:•monitor and evaluate the change•maintain and reinforce the change2. REINFORCING IMPROVEMENT:•reinforcing or motivating factors by the management .•integration of audit as part of regular practice•strong leadership and high motivation6. RE-AUDIT:-Review evidence-Measure effectiveness-Decide how often to re-audit- Ongoing process monitoring-Adverse incidents-Significant events audit
TYPES OF CLINICAL AUDIT X -RAY REVIEW STATISCIAL DISEASE AUDIT AUDIT MEDICAL DEATH OBSTETRIC AUDIT CASES AUDITRANDOM CASE NURSING INFECTION TISSUE/OPERATION AUDIT AUDIT CONTROL CASES
1.STATISTICAL AUDIT It is the first step in Medical Audit.i) Data on different indicators set by audit committee are prepared unit wise on monthly basis.ii) A standard norm is evolved taking into consideration of available facilities, services, resources by an expert committee.iii)The data so obtained is critically examined and compared against the standard norms.iv)Deviation from standard norm dictates investigation to find out possible cause and its remedial measure.v) The data are generated, compiled and supplied by MRD.
INDICATORS USED NET DEATH RATE INFECTION RATE < 4% < 2%AVERAGE LENGTH OF CONSULTATION STAY 7 TO 10 DAYS INDICATORS RATEBED OCCUPANCY AUTOPSY RATE 80% < 15% BED TURN OVER ANAESTHETIC DEATH RATE < 1% 6 TO 10 DAYS
2.AUDIT OF DISEASE CASES This is the second step in Medical Audit.-It starts with the case record examination of a particular disease(Typhoid)-All case sheets are arranged unit wise and month wise.-A group of physicians are asked to lay down certain norms withrespect to a) Investigations to be done b) Line of treatment c) Average length of stay d) Likely complications-Then the case sheets are examined as per the above norms tofind out difference.-The unit in which short coming is detected in one of abovecriteria are asked to rectify and improve.- This helps in learning, education and improvement in qualitycare.
3.AUDIT OF OPERATED CASESIn this group patients operated for similar surgicalmethod are identified (Laparoscopic Chole- cystectomy)-The cases are grouped as unit wise and month wise.-A group of experts are asked to lay down certain norms in respectof the following: i) Methodological Approach ii) Percentage of pre-operative diagnosis confirms the surgery iii) Types of pre- anaesthetic check up iv) Types of post operative complications v) Anesthetic Complications vi) Patient consent, safety check list vii) Use of Antibiotics-Then the case sheets are examined in light of above norms.-Shortcomings are intimated to concern unit for future precautionand rectification.
4. AUDIT OF OBSTETRIC CASES The indicators used are same as operation cases and in addition.-No. of C.S done with indications.-No. of forceps/ vacuum application-No. of Material Complication-No. of Maternal or Neonatal Death
5. AUDIT OF RANDOM CASESIn this method some case sheets of discharged patients are randomly selected during a month. The objective of this type of audit is to study the quality of record maintenance, diagnostic deficiency, treatment and outcome. The various parameters used:-a) History, Physical Examination, Diagnostic Skillsb) Investigations done, Treatment given, Progress notec) Nursing Care Chartd) The initial diagnosis is compared with final diagnosis after investigation.e) Treatment given is judged against correctness, adequacy according to norms.f) The end result of treatment is compared with patient condition at discharge.g) Any deviation found from the norms are intimated for improvement.
6. AUDIT OF DEATH CASES This is also called death review. All deaths occurring after 48 hours of admission should be subjected to Medical Audit. The death case sheets are examined in terms of qualitative and quantitative adequacy. The various parameter used are:a) The diagnosis, investigation, treatment given in comparison to normal standard.b) Delay in examination, investigation or initial treatment.c) Types of consultations obtained and recorded.d) Daily Monitoring of Progress. The various inadequacies found by the committee are communicated to respective units for taking preventive measures and improvement in future.
7. NURSING AUDITNursing audit, is a review of the patient recorddesigned to identify, examine, or verify the performance ofcertain specified aspects of nursing care by usingestablished criteria.The clinical audit process seeks to identify areas forservice improvement, develop & carry out action plans torectify or improve service provision and then to re-audit toensure that these changes have an effectIn this case the medical records are examined withrespect to type of nursing care given.Special care, Input Output, O2 inhalation, Monitoringrecord TPR chart, daily nursing note etc.The audit may be retrospective or introspective
EVALUATION OF QUALITY OF CARE QUALITY OF QUALITY OF ART ADMINISTRATIVE TECHNICAL CARE OF CARE. SUPPORT(a) Technical care: can be assessed by adequacy ofdiagnostic and therapeutic processes.(b) Art of care: Manner and behaviour of provider in deliveringcare and communication with patient.•A doctor is expected to know not only how to treat a patient butalso treat dying patient.(c) Administrative support : Planning, organising & directingall resources for patients care to maximise productivity towardsbetter patient care based on evaluation report.
ROLE OF HOSPITAL ADMINISTRATION IN AUDIT (a) To facilitate and provide good working environment. (b) To provide physical facilities, resources and smooth supply. (c) To motivate to enable the medical care providers to work enthusiastically. (d) To attend patient complain, grievances by grievance redressal committee. (e) To edit& monitor media coverage/press notes. (f) Patient satisfaction surveys to reveal the grey areas. (h) To conduct exit interview & make changes as suggested. (i) To frame clear cut objectives & policies.
ADVANTAGE OF CLINICAL AUDIT An educational activity Promotes understanding Resource effective Raises standards Promotes change Source of information Peer led and peer understanding Involves patients
PROBLEMS IN MEDICAL AUDITLack of organized medical recorddepartment.Incomplete record, poor quality maintenance.Fear of action and lack of motivation ofmedical staff.Ignorance of value of medical audit byhospital staff.Suppression of facts, wrong reporting,Completion of records after death restrict thetrue value of medical audit.
CONTENTS OF AN AUDIT REPORT Background Literature review Criteria and standards Methods or protocol used Results Recommendations for change Recommendations for further audit
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