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Medical Audit

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Medical Audit

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Medical Audit

  1. 1. MEDICAL AUDIT
  2. 2. CONTENTS • Definitions • History • Need and Purpose • Prerequisite • Medical audit committee • Principles • Stages • Types • Limitations • Place of medical audit in modern medicine
  3. 3. DEFINITION
  4. 4. 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.
  5. 5. 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’
  6. 6. HISTORY
  7. 7. 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.
  8. 8. 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.
  9. 9. NEED&PURPOSE
  10. 10. 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.
  11. 11. PURPOSE OF MEDICALAUDIT 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.
  12. 12. PREREQUISITES FORMEDICALAUDIT
  13. 13. 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.
  14. 14. 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.
  15. 15. MEDICALAUDITCOMMITTEE
  16. 16. 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.
  17. 17. PRINCIPLESOFMEDICALAUDIT
  18. 18. 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.
  19. 19. 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.
  20. 20. STAGESOFMEDICALAUDIT
  21. 21. 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 methods Creating the environment
  22. 22. 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
  23. 23. 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
  24. 24. 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.
  25. 25. 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 %.
  26. 26. 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..
  27. 27. STAGES STAGE ONE Preparing for audit STAGE TWO Selecting criteria STAGE THREE Measuring performance STAGE FOUR Making improvements STAGE FIVE Sustaining improvement Using the methods Creating the environment
  28. 28. STAGE1. PREPARING FOR AUDIT 1. Involving users 2. Selecting a topic 3. Defining the purpose 4. Planning
  29. 29. 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.
  30. 30. 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).
  31. 31. 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
  32. 32. 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.
  33. 33. 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
  34. 34. 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.
  35. 35. 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
  36. 36. STAGES STAGE ONE Preparing for audit STAGE TWO Selecting criteria STAGE THREE Measuring performance STAGE FOUR Making improvements STAGE FIVE Sustaining improvement Using the methods Creating the environment
  37. 37. STAGE 2. SELECTION OF CRITERIA 1. Defining criteria 2. Sources of evidence 3. Appraising the evidence
  38. 38. 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.
  39. 39. 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.
  40. 40. 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
  41. 41. 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.
  42. 42. 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.
  43. 43. 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.
  44. 44. 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."
  45. 45. 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.).
  46. 46. 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.
  47. 47. 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
  48. 48. 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
  49. 49. EXAMPLE-ECLAMPSIA
  50. 50. STAGES STAGE ONE Preparing for audit STAGE TWO Selecting criteria STAGE THREE Measuring performance STAGE FOUR Making improvements STAGE FIVE Sustaining improvement Using the methods Creating the environment
  51. 51. STAGE 3. MEASURING LEVEL OF PERFORMANCE 1. Data collection 2. Data analysis 3. Comparing with standards set 4. Dissemination of feedback findings
  52. 52. 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.
  53. 53. • 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
  54. 54. 2. DATAANALYSIS • 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.
  55. 55. 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
  56. 56. 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.
  57. 57. STAGES STAGE ONE Preparing for audit STAGE TWO Selecting criteria STAGE THREE Measuring performance STAGE FOUR Making improvements STAGE FIVE Sustaining improvement Using the methods Creating the environment
  58. 58. STAGE 4. MAKING IMPROVEMENTS 1. Identifying barriers to change 2. Implementing change
  59. 59. 1. IDENTIFYING BARRIERS TO CHANGE  Fear  Lack of understanding  Low morale  Poor communication  Culture  Pushing too hard  Consensus not gained
  60. 60. 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
  61. 61. 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
  62. 62. STAGES STAGE ONE Preparing for audit STAGE TWO Selecting criteria STAGE THREE Measuring performance STAGE FOUR Making improvements STAGE FIVE Sustaining improvement Using the methods Creating the environment
  63. 63. STAGE 5. SUSTAINING IMPROVEMENTS 1. Monitoring and evaluation 2. Re-audit 3. Maintaining and reinforcing improvement
  64. 64. 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.
  65. 65. 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).
  66. 66. 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
  67. 67. EXAMPLE Problem : 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.
  68. 68. 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).
  69. 69. 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.
  70. 70.  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.
  71. 71. 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.
  72. 72. TYPESOFMEDICALAUDIT
  73. 73. 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.
  74. 74. 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.
  75. 75. 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.
  76. 76. 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
  77. 77. ON SPOT MEDICALAUDIT  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.
  78. 78. LIMITATIONS
  79. 79. 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.
  80. 80. 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.
  81. 81. PLACEOFMEDICALAUDITINMODERN HEALTHCARE
  82. 82. PLACE OF MEDICALAUDIT 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.
  83. 83. PLACE OF MEDICALAUDIT 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
  84. 84. PLACE OF MEDICALAUDIT 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.
  85. 85. 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
  86. 86. THANK YOU

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