medical audit administration

8/8/2019 Medical Audit Administration

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MEDICAL AUDIT AND ITS ADMINISTRATION

The case is a 19-years old girl, VivianLabourton..Got a lump below her leftknee, persistent pain. X-ray shows somebone irregularity. These slides are fromthe biopsy.

There are eight slides and colemanstudied each in turn.At the end he said,

My opinion is benign. I think its

malignant, Pearson said quietly .And if Iam wrong, a 19-years-old girl will lose aleg for nothing.


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May I suggest we check past cases.Coleman said, cases with somesymptoms?

The old man shook his head. No good.It would take to long. Trying to bediscreet, Coleman persisted, But surely ifwe checked the cross file.He paused .

We havent got one. It was said softly,

and at first Coleman wondered if he hadheard it right.


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Nothing that Pearson might have saidcould have shocked David Coleman quiteso much as this. To him, and to allpathologists whom he had trained andworked with until now, the cross file wasan essential professional tool. It was asource of reference, a means of teaching,a supplement to a pathologists ownknowledge and experience, a detectivewhich could assimilate clues and offersolutions, a means of reassurance, and astaff to lean on in moments of doubt.


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INTRODUCTION

This is perhaps a laymans introduction tomedical audit in retrospect. It helps tounderstand the validity of a procedure conductedin the past, which become a source of reference

for the future, and forms what is known as theessence of medical audit. The final diagnosis ofthe pathologist in the book (Hailey1959) is aresult of years of experience, where instinct andintuition play a crucial role in avoiding a nearmiss. In order to discharge their duties as

responsible medical professionals, doctors requireeducation and experience. Medical audit is a toolwhich ensures a high level of knowledge throughthe constant pursuit of observation and inquiry.


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MEDICAL AUDIT

The history of medical audit can be tracedto Dr. George Gray Ward, a notedgynecologist at the womens Hospital, NewYork City. He was the secretary of

American Gynecological Society, from1917 to 1921, and its president in 1922.He considered medical audit a systematicreview and analysis of all patients whowere treated by him. He put into practiceprobably the first organized medicalaudit, emphasized the importance ofmaintaining accurate medical records, andpaid great attention to the study of endresults. Medical audit was suggested as aregular feature for all government


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An evaluation system in whichestablished standards are used tomeasure performance . Once corrective

action has been taken about problemsidentified through a review process,performance is re-measured after anappropriate time period.


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The following are acknowledge as theattributes of medical audit:

It aims to improve the quality of medicalcare. It compares actual medical practice with

agreed standards of practice. It is formal and systematic.

It involves peer review. It requires the identification of variations

between practice and standards followingby the analysis of causes of such

variations. It provides feedback for those whoserecords are audited.

It includes following up or repeating anaudit some time later, to find out if thepractice is fulfilling the agreed standards.


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Medical audit is justified on the basis that it is astimulus to the practice of scientific medicine,and an objective and specific check on theprofessional tasks performed in the hospital. Inthis context, it has frequently been comparedwith financial audit. Over the years people have

argued, If it is important to have an audit inrupees, is it not more important to have an auditof the professional work of the hospital anaccount of the medical care rendered in terms oflives saved avoidable and unavoidable deaths,diseases averted and patients rehabilitated ?

There is therefore, a need for medical audit.There is no doubt that this would lead toimproved patient care, as well as a reduction inhospital expenditure, due to the better utilizationof hospital facilities, and avoidance of wastefuland unproductive methods.


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It should be noted that there exists aprofessional motive for auditing medical practice.

Most medical students graduate as altruisticphysicians, wishing to provide the best possiblecare to their patients. Medical audit fosters thisaltruism and provides a system for generatingself-correcting and self-regulating improvementsin their practice. It also encourages and helps

them to maintain a high quality practice. Thenthere is a social motivation too. All doctors areaccountable to the people they serve, how theydispose off the resources made available to themand provide good service to the best of theirabilities. Thus, medical audit fosters botheffectiveness and efficiency, In addition to this,it ensures that patients receive optimum care,and helps in avoiding unnecessary risks in theprovision of that care.


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Medical audit provides the relevantinformation by means of which doctorsand other health care professionals candefend themselves against criticism,

support claims for more resources, andimprove on the deficiencies in theirservice. As a corollary to this, it helpsmedical practitioners provide evidence tofunding agencies, and informs managersof the need for more resources forimproved efficiency.


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Medical audit thus helps in streamlininghospital procedures, by exposing the

bottlenecks in the diagnostic, therapeuticand supportive services of a hospital. Forthis purpose, a systematic procedure foraudit is required, protocols need to be laiddown all the individuals involved need to

be motivated, and the relevance of suchan exercise should be explained to them.The idea that it is not policing but a steptowards greater knowledge andunderstanding, by way of joint effort, is

what will determine the success of such anendeavour .


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PROTOCOLS

Protocols for medical audit need to address thefollowing questions.

Who is being audited?

Who is auditing?

What is being audited? How is the audit conducted?

How often and when is the audit conducted?

Clarity regarding these issues will lay thefoundation for starting a medical audit in ahospital. The following components should forman integral part of a medical audit protocol:


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COMMITTEE

A medical audit committee should beconstituted, comprising the followingprofessionals from the medical section:

Director of Medical Services

Head of medical departments (Medicine,Surgery, Obstetrics and Gynecology,Pediatrics)

Head of Pathology Nursing Superintendent

And the following from the administrativesection :

CEO / MD

Administrators


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In case the CEO / MD and / orAdministrators do not have a medicalbackground, they are only observers at

committee meetings. In addition to this,depending on the area of audit, certainother administrative personnel could forma part of this committee. For example,

the bio-medical in- charge in anequipment audit.


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FREQUENCY OF AUDIT

The audit should be conducted in thefollowing manner:

Periodic / regular : Monthly audit of cases

( this includes death cases collected over amonth). This periodicity is subject to thepatient turnover in the hospital .

Surprise checks of medical recordsconducted fortnightly.


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ELEMENTS OF AUDIT

Case audit

Mortality review

Complications audit

Antibiotic utilization

Overstay audit

Investigation audit

Check sheet: pre-operative, pre-anesthetic, pre- procedural


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Infection control audit Hospital acquired infection Environmental infection Critical areas audit, such as, ICUs, OT , burns,

dialysis Standard operating procedures laid down for

these areas, to be strictly followed. Medical record audit Resource utilization

Frequency of consultation. Frequency of sample collection. Frequency of usage of consumables. Frequency of usage of OT, diagnostics,

physiotherapy, the medico social worker

(f) Equipment audit


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Audit needs to be organized in such a waythat leads to the maximum participation ofthe organization, with the prime objective

of improving hospital services. Files shouldnot be opened to evaluate personnel andlabel them good or bad. A we approachwould go a long way in making auditacceptable. In order to carry out a

complete review, each area of auditshould have a predetermined checklist.The elements which could serve asindicators of how to carry out a medical

audit are described in detail.


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CASE AUDIT

An ideal subject for audit would be acommon, well defined, clinicallysignificant diagnosis or treatment.


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MORTALITY REVIEW

Autopsies should be performed. The finaldiagnosis, or the cause for the death mustbe given by the pathologist. Once a deathhas occurred, it is necessary that themedical records are sealed, so that noalterations can be made. The cases arethen opened at the Mortality Reviewmeeting, and the details of the casesheets are discussed and debated. Thefactors under consideration for discussionin the meeting include the validity ofdrugs administered, the dosage, anyreactions to the drugs, complicationsarising out of the disease and so on. Theinformation for this review is built from

the data collected in autopsy.


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COMPLICATIONS AUDIT

Complications occurring must bedetermined by verifying observations withthe drugs therapy, or a change in therapy,

and laboratory and radio-imageologicalfinding. It should be stated that thecomplications were due to causes beyondthe doctors control, whether it was due to

the natural course of the illness or resultof poor management on the part of themedical,paramedical or hospital staff.


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Passing the buck in such situations can

only serve to aggravate defensive

behavior. But a planned programme faults

and finding alternative solutions through

direct training and involvement of all those

concerned, would go a long way in

consolidating interrdepartmental co-operations.


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medical audit administration

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