Medical audit

1. MEDICAL AUDIT
Dr. Rajesh Ranjan
MBBS(MAMC), DHA, MD(CHA),
DNB(Hospital Admin.), AFIH
Associate Professor, Dept. of Medical care and
Hospital Admin., NIHFW
Ex. CEO and Professor, Dept. of Community
medicine,
NIIMS, Greater Noida

2. How can you improve patient
care in hospitals
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3. How can you improve patient
care in hospitals
 Govt. versus private organizations
 Evidence based versus individual based
 Protocol based versus every time different
approach (changing protocols as per
physician)
 Is the change evidence based
 General Physician versus speciality
hospitals
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MEDICAL AUDIT
A Tool
A Technique
For Evaluation of Care
It’s application is
A Science
An Art
An innovation in Medical Science

5. Most widely accepted definition
of Medical Audit
 Evaluation of medical care in retrospect
through analysis of medical records.
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Aim of Medical Audit
 Patients in a hospital should receive the
best care modern medicine has to offer.

8. MEDICAL AUDIT
OBJECTIVE
a) To raise the quality of medical care rendered to inpatients.
b) To streamline the hospital procedures and practices.
c) To find out the bottle necks in diagnostic, therapeutic and supportive
services in the hospital.

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“ we have granted the health profession access to the
most secret and sensitive places in ourselves and
entrusted to them matters that touch on our well
being, happiness and survival.
In turn, we have expected the professionals to govern
themselves so strictly that we need have no fear of
exploitation or incompetence. The object of quality
assessment is to determine how successful they have
been in doing so; and the purpose of quality
monitoring is to exercise constant surveillance so that
departure from standards can be detected early and
corrected”
Prof. Avedis Donabedian

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Origin of Medical Audit
 “A physician who fails to enter the body of
a patient with the lamp of knowledge and
understanding can never treat
diseases……..”
“Charakha-Samhita”
 Code of king Hammurabi of Babylon 2000
BC

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 Hippocrates (460-377 BC)
 Flexner Report, 1910, reg: appalling
conditions in many American & Canadian
Medical Schools
 Dr. E. Codman of Boston & Dr. Edward
Martin of Philadelphia, 1910, : “ End Result
System of Hospital Organization”
Establishment of American College Of
Surgeons
 New York, 1912, Margaret Sanger

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 New York, 1918, George Gray Ward, a
gynecologist, conducted first organized
Medical Audit in U.S.A
 Dr. Malcolm T, Mac Eachern - American
College of Surgeons - Hospital
Standardization Program
 1924, Development of MINIMUM
STANDARDS

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 Late 1950- American College Of Surgeons invited
American College Of Physicians, American Hospital
Association & American Medical Association – The
Joint Commission On Accreditation Of Hospitals
(JCAH)
 1973, JCAH enforced Medical Audit
 1st Jan, 1972, the US Congress enacted the law for
Medical Audit. This law stipulates three functions-
that the medical services are:
 Medically necessary
 Of professionally recognized standard of quality
 Of a proper level of care & of proper duration

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History of Medical Audit
Obviously lays the responsibility of
Medical Audit on:
The medical professionals
The institutions

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Medical Audit
 Is far more important to a hospital than
Financial Audit

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A Need For Systems Approach
Patient
Clinical skills
&
Ethics
Technology

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Definition And Concept
“ Life is short, and the art long; the occasion
fleeting; experience fallacious, and judgment
difficult. The physician must not only be
prepared to do what is right himself but also to
make patients, the attendants, and the
externals to cooperate.”
Hippocrates 400 BC

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Good clinicians have always organized
some kind of systematic review of their
daily work and it is Medical Audit.

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Definition of Medical Audit
 Audit- “an official examination and
verification of accounts of dealing.”
Webster Dictionary
 “ Review of professional work in the
hospital, that could take place whenever,
medical staff meet to analyse the hospital
clinical work”
Dr. Mudaliar

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 “ is the evaluation by the physicians of the
quality of patient care as revealed by medical
records.”
Myers & Slee
 “ it is a systematic approach to peer review of
medical care in order to identify opportunities for
improvement & provide mechanism for realizing
them.”
 It is the examination of professional dealings by
clinicians & their verification according to the
standards or criteria, on the basis of data
collected through professional accounting system
in hospitals i.e. Medical Records.

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Medical Audit By Any Other
Name?
Medical Care Evaluation
Health Standards Assessment
Clinical Activity Assurance
Professional Quality Audit
Review
Monitoring

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Guidelines For Medical Audit
Seven Principles :
by Charles. D. Shaw
1) Health authorities and medical staff should
define explicitly their respective
responsibilities for the quality of patient care
2) Medical staff should organize themselves in
order to fulfill responsibility for audit and for
taking action to improve clinical performance

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3) Each hospital and speciality should agree to a
regular program of audit in which doctors in all
grades participate
4) The process of audit should be relevant,
objective, quantified, repeatable and able to effect
appropriate change in organization 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

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Quality Of Medical Care
 Quality : refers to the degree of conformity with
standards, with the best of medical knowledge
and with accepted principles and practices.
 Medical Care : includes only those elements of
care which are provided by, or under specific
direction of the physician
 Evaluation : is carried out by matching
procedures against approved standards
 Standards: are laid down on the basis of medical
knowledge which provide us with information
about what should be done in order to achieve
the best results

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Evaluation of Care In Hospitals
 Evaluation of Inputs - Staff
- Physical Facilities
- Materials
 Evaluation of Process - Administrative
- Technical
- Clinical
(Medical & Nursing)
 Evaluation of outputs - Benefits to the users of care
Input ---- Process----Output

26. Methods used in Medical Audit
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Types of Medical Audit
Internal Audit (Peer
Review)
External Audit
Continuously by hospital
staff
By outside agency
Abstracting & classifying
clinical record and
evaluating quality of
medical care
Periodically tests
completeness & accuracy
of internal audit
Review by practicing
physicians
Review by non-medical
administrators e.g.. PSRO

28. Types of Medical Audit
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29. PRE-REQUEST FOR MEDICAL AUDIT
MEDICAL
AUDIT
MEDICAL AUDIT
COMMITTEE
WELL ORGANIZED
MEDICAL RECORD

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Pre-requisites To Medical Audit
 Good organized medical records
 Establishment of Norms / Standards
 Establishment of organizational structure to
conduct Medical Audit
 Training of staff on Method, Philosophy &
Mechanism of Medical Audit
 Co-ordination / Co- operation
 Confidentiality to be assured

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Phases of Medical Audit
 Medical Accounting: Provision of adequate
records, which will be the basis of analysis
 Actual analysis and drawing inference

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Medical Records
 It is a clinical, scientific, administrative
and legal document relating to patient’s
care, in which are recorded sufficient data,
written in the sequence of events to justify
diagnosis and warrant treatment and the
end results

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Importance of Medical Records
 Continuity of Patient Care
 Medical Education & Research
 Analysis & Planning of Hospital Services &
Facilities
 Credentialing of Health Care Professionals
 Utilization Review
 Quality Assessment

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Setting Of Standards
 Quality starts with standards
 Standards should be
Objective
Verifiable
 Uniform
 Specific
 Acceptable

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Medical Audit- A Technique For
Medical Education
 Critical review of current practices & comparison
against predefined standards. Encourages
updating of knowledge
 Identification of key features of clinical practice
leads to relevant lessons to be learned
 Suggests need for improvement of knowledge &
research
 Self evaluation & peer review are important
components of post graduate education

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Continuing evaluation stimulates improved
clinical services, professional education,
hospital administration & better patient
care.
THIS IS MEDICAL AUDIT

37. Methodology
 Criteria Development
 Selection of Cases within Diagnosis
 Work Sheet Preparation
 Case Evaluation
 Tabulation
 Report Presentation

38. Criteria Development
 Choose the diagnoses to be studied:
depending upon the case load/ mortality
profile/public health importance etc by
committee
 Indications for admission
 Hospital services recommended for optimal
care
 Range of length of stay & indications for
discharge
 Complications or additional diagnoses

39. Work Sheet (tool) Preparation
 Standard worksheet, A Structured worksheet with
YES, NO, NA to be prepared on which pertinent data
are taken from records of patient.
 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

40. Case Evaluation
 All members of medical staff regardless of
speciality to be involved in evaluation, a
group of five clinicians is considered
optimum by Payne
 Admission: appropriate/ inappropriate
 Length of stay: appropriate/ inappropriate
 Hospital services:Adequate/inadequate
 Comments

41. Applications:
 Adequacy & quality of care
 Caesarean cases study & Unnecessary
surgery study
 Educational tool
 Evidence based medicine
 Scientific approach
 Professionalism

42. Medical Audit Committee
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43. Do we really need
Medical Audit
Who all are getting benefitted?
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Importance of Medical Audit -
To The Patients
 Better care as scientific work is kept at highest plane
of efficiency
 Attending clinician leaves nothing undone including
cross consultations, if required
 Technical staff ensures updating of knowledge &
techniques
 Diagnostic facilities are up to highest available
standards
 In patient services ensure prevention of infection &
other morbidity
 Improvement in total care will- Reduce Mortality Rate
- Decrease AVLS

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To The Hospitals
 Analysis of professional work
 Reveals weaknesses, if any
 Emphasize points of strength
 Ensures improvement in medical practice
 Administration gets clear statements of the
results produced & can then compare with
comparable institutions
 The above self analysis strengthens feeling of
confidence in the community & thus enhances
reputation of the hospital.

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To The Community
 Curative – members of the community
find themselves be treated in accordance
with the best medical care
 Preventive- systematic examination of
individuals, is showing marked results in
early diagnosis & prevention of diseases,
e.g. Cancer

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To The Clinicians
 Increased clinical efficiency by the procedure of
medical audit & associated staff conferences
 Stimulus for CME
 Knowledge of newer modalities of treatment ,
variations in surgical techniques
 Intellectual stimulus
 Co-operation & fellowship is promoted
 Serves to rouse the clinicians to perform at his/ her
best, all the times

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Need For Medical Audit
 Ensures safe, efficient & effective medical care
 Locates inadequacies & defects
 Evaluates utilization of resources
 Reviews administrative policies
 Ensures accountability of Personnel
 Helps maintain hospital discipline
 Professional protection to the providers of
medical care
 To provide the public a feeling of security that
the clinicians are doing their best

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Inhibitions To Medical Audit
 It will simply describe what the doctors are
doing, without regard to the efficacy of their
treatment. But, this will happen only when
review is conducted without using criteria
based on best available evidence of efficacy
 May be embarrassing. But, embarrassment is
preferable to ignorance

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 Introduction of criteria may make them
rigid rules, difficult to change & inhibit
innovation. But, this does NOT happen.
Process of criteria setting is to be open &
substantiated by suitable references in
medical journals etc.
 Threat to freedom. Distrust. Suspicion.
Resistance to change.
And it is here that how Medical Audit is
implemented is vital.

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Implement Medical Audit
 Motivation
 Preparation
 Strong professional commitment
 Administrative support
Conforming with their traditions and objectives of
providing international quality health care – hospitals, that
are centers of excellence & pride of our country are taking
up the challenge of medical audit as their noblest
experiment which will have a salutary influence on patient
care.

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Confidentiality to be assured.
 Aim of the Medical Audit Committee is –
Critical analysis of the process of
medical care delivered
AND, NOT THE PERSON WHO
DELIVERED THE CARE.

53. Types of Medical Audit
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54. Difference between Medical
and Clinical Audit
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55. Types of Clinical Audit
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56. 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, complied and supplied by MRD.

57. INDICATORS USED
INDI
CAT
ORS
NET DEATH RATE
< 4%
AVERAGE LENGTH OF
STAY 7 TO 10 DAYS
BED OCCUPANCY
80%
BED TURN OVER
RATE
INFECTION RATE
< 2%
CONSULTATION
RATE
AUTOPSY RATE
< 15%
ANAESTHETIC DEATH
< 1%

58. 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 with respect 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 to find out difference.
-The unit in which short coming is detected in one of above criteria are asked to
rectify and improve.
- This helps in learning, education and improvement in quality care.

59. AUDIT OF OPERATED CASES
-In this group patients operated for similar surgical method are identified
(Laparoscopic Cholecystectomy)
-The cases are grouped as unit wise and month wise.
-A group of experts are asked to lay down certain norms in respect of 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) Anaesthetic 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 precaution and rectification.

60. 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

61. AUDIT OF RANDOM CASES
- In this method some case sheets of discharges 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 Skills
b) Investigations done, Treatment given, Progress note
c) Nursing Care Chart
- The initial diagnosis is compared with final diagnosis after investigation.
- Treatment given is judged against correctness, adequacy according to norms.
- The end result of treatment is compared with patient condition at discharge.
- Any deviation found from the norms are intimated for improvement.

62. 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 improve in future.

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64. Role of Hospital Administration
in Conduct of Medical Audit
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 Healing is a divine art and clinician is
seen as a conduit of divine grace.
 This assumption in the divine origin has
the capacity to produce unshakable Faith.
 Faith breeds Trust. These two factors are
very important in any treatment.
 This spiritual & emotional aspect is still
very vital to the patients and public in our
country.
 Though commercialization has turned a lot
many scales.
 Hospital administrators & clinicians need
to clarify details of their commitment.

66. THANK YOU
Food for thought