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MEDICAL AUDIT




         DR. N. C. DAS
WHAT IS AUDIT
A systematic and critical appraisal of the planning,
delivery and evaluation of service/s in terms of
effic...
WHY AUDIT

•Maintain participant and staff safety.
•Maintain data quality .
•Protect reputation of staff, organiser and ho...
TYPES OF AUDIT
AUDIT MAY BE INTERNAL OR EXTERNAL
                  MANAGERIAL/
                 ORGANISATIONAL




   MEDI...
DIFFERENT AUDITS
Distinctions have been drawn between different
types of audit in terms of the focus of the
activity and t...
METHODS USED IN AUDIT



  Direct observation
  Checklists
  Documentation/records audit
  Questionnaires
  Interview...
WHAT IS MEDICAL AUDIT

"Medical Audit" is a planned review programme which
objectively monitors and evaluates the clinica...
TYPES OF CLINICAL AUDIT




                        CLINICAL AUDIT
       CONCURRENT                        RETROSPECTIVE
...
NEED FOR MEDICAL AUDIT


1. For Professional
•Health care providers can identify their lacunae &
deficiencies and make nec...
PURPOSE OF CLINICAL AUDIT
1. To plan future course of action, it is necessary to obtain
   baseline information through ev...
PRE-REQUISITE FOR CLINICAL AUDIT



                CLINICAL
                 AUDIT



MEDICAL AUDIT                WELL O...
1.MEDICAL AUDIT COMMITTEE


  Hospital Administration       -   Chairman
  Officer In charge MRD         -   Member Secret...
2. MEDICAL RECORD
-All the junior staff (Residents) to be trained and
retrained how to fill up the medical records.
-All t...
SIX STAGES OF CLINICAL AUDIT
                      STAGE –I
                 PREPARING FOR AUDIT

                      ST...
STAGE 1: PREPARING FOR AUDIT

                      USERS
                   INFORMATION




     PLANNING                ...
1. USERS INFORMATION


The concerns of users can be identified from
various sources, including:
-Letters containing commen...
2. SELECTING A TOPIC


-starting point
-careful thought and planning
- There seems little point in trying to audit
a rare ...
3. MEASURE FOR PRIORITISE

Is the topic concerned is of high cost, or risk to
staff or users?
Is there evidence of a ser...
4. DEFINING THE PURPOSE

-purpose must be established before appropriate
methods for audit can be considered.
-Once topic ...
5. PLANNING AUDIT



Involve ALL the people concern.
 Fix time and Plan resources
Access the evidence/data
Methodology...
STAGE 2: SELECTION OF CRITERIA




         APPRAISING
                      DEFINING
             THE
                   ...
1. DEFINITION OF CRITERIA


-Which area:-
-an individual, a team, or an organisation
-This can include assessment of the p...
2. SOURCES OF EVIDENCE


Systematic methods should be used
• Good-quality data
• Reviews of the past audit
• Previously us...
3. APPRAISING THE EVIDENCE


Evidence needs to be evaluated to
find out if it is valid, reliable and
important.
 Meeting ...
STAGE 3: MEASURING LEVEL OF
       PERFORMANCE


                  HANDLING
                    DATA




         METHODS ...
1. PLANNING DATA COLLECTION



   -The data collected are to be precise
   -Essential data
   -Completed data
   - Adequat...
2. METHODS OF DATA COLLECTION

•Do not try and collect too many items, keep it simple and
short, relevant to present study...
STAGE 4: MAKING IMPROVEMENTS




                 MAKING IMPROVEMENTS
                                       CHANGE BY
   ...
1. IDENTIFYING BARRIERS TO CHANGE


        - Fear
        - Lack of understanding
        - Low morale
        - Poor com...
2. IMPLEMENTING CHANGE



systematic approach:
•identification of local barriers to change
•change culture
•Provide suppor...
STAGE 5: SUSTAINING IMPROVEMENT




                           MONITORING
           REINFORCING
                         ...
1. MONITORING AND EVALUATION:
systematic approach to changing professional practice
should include plans to:
•monitor and ...
TYPES OF CLINICAL AUDIT


                     X -RAY REVIEW
   STATISCIAL                                DISEASE
     AUD...
1.STATISTICAL AUDIT
      It is the first step in Medical Audit.
i) Data on different indicators set by audit committee ar...
INDICATORS USED


 NET DEATH RATE                      INFECTION RATE
      < 4%                                < 2%



AV...
2.AUDIT OF DISEASE CASES
     This is the second step in Medical Audit.
-It starts with the case record examination of a p...
3.AUDIT OF OPERATED CASES
In this group patients operated for similar surgical
method are identified (Laparoscopic Chole- ...
4. AUDIT OF OBSTETRIC CASES
    The indicators used are same as
    operation cases and in addition.

-No. of C.S done wit...
5. AUDIT OF RANDOM CASES
In this method some case sheets of discharged patients are
   randomly selected during a month.
...
6. AUDIT OF DEATH CASES

              This is also called death review.
 All deaths occurring after 48 hours of admissio...
7. NURSING AUDIT

Nursing audit, is a review of the patient record
designed to identify, examine, or verify the performan...
EVALUATION OF QUALITY OF CARE

    QUALITY OF         QUALITY OF ART    ADMINISTRATIVE
  TECHNICAL CARE         OF CARE.  ...
ROLE OF HOSPITAL ADMINISTRATION IN AUDIT

  (a) To facilitate and provide good working
  environment.
  (b) To provide phy...
ADVANTAGE OF CLINICAL AUDIT



      An educational activity
      Promotes understanding
      Resource effective
    ...
PROBLEMS IN MEDICAL AUDIT

Lack of organized medical record
department.

Incomplete record, poor quality maintenance.

...
CONTENTS OF AN AUDIT REPORT


   Background
   Literature review
   Criteria and standards
   Methods or protocol used...
hospiad

                      Hospital Administration Made Easy




               http//hospiad.blogspot.com
    An effo...
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Clinilal audit

  1. 1. MEDICAL AUDIT DR. N. C. DAS
  2. 2. WHAT IS AUDIT A systematic and critical appraisal of the planning, delivery and evaluation of service/s in terms of efficiency, effectiveness and quality, within given resources. Evaluation of data, documents and resources to check performance of systems if meets specified standards. 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.
  3. 3. 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
  4. 4. TYPES OF AUDIT AUDIT MAY BE INTERNAL OR EXTERNAL MANAGERIAL/ ORGANISATIONAL MEDICAL AND FINANCIAL CLINICAL
  5. 5. DIFFERENT AUDITS Distinctions have been drawn between different types of audit in terms of the focus of the activity and the personnel involved. Thus: * medical audit involves the review of activities initiated directly by doctors * clinical audit covers all aspects of clinical care including that provided by nursing and paramedical staff * organisational audit refers to investigation of aspects of practice such as appointments systems, policies, practices, standards which are regarded as primarily administrative functions.
  6. 6. METHODS USED IN AUDIT Direct observation Checklists Documentation/records audit Questionnaires Interviews Clinical Case review
  7. 7. WHAT IS MEDICAL AUDIT "Medical Audit" is a planned review programme which objectively monitors and evaluates the clinical performance of all practitioners, records by qualified professional personnel to identify, examine,or verify the performance using established criteria. There by identifies opportunities for improvement, and suggests mechanism through which action is taken to make and sustain those improvements. The systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome and quality of life for the patient Clinical Audit A quality improvement process that seeks to improve patient care and outcomes through systematic review of care of health care team against explicit criteria and the implementation of change.
  8. 8. TYPES OF CLINICAL AUDIT CLINICAL AUDIT CONCURRENT RETROSPECTIVE AUDIT AUDIT Care is evaluated at care is evaluated after it the time it is taking has been completed place through records.
  9. 9. NEED FOR MEDICAL AUDIT 1. 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 from care that is inappropriate, suboptimal & harmful. 3. For health promotion •To reduce patient sufferings and avoid the possibility of denial to the patients of available services or injury by excessive or inappropriate service.
  10. 10. PURPOSE OF CLINICAL AUDIT 1. To plan future course of action, it is necessary to obtain baseline information through evaluation of achievements 2. 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 performance 6. Help developing explicit standards 7. Suggests what needs to be changed 8. Help Mobilise resources for change 9. Reviews the past and modify the present process
  11. 11. PRE-REQUISITE FOR CLINICAL AUDIT CLINICAL AUDIT MEDICAL AUDIT WELL ORGANIZED COMMITTEE MEDICAL RECORD HOSPITAL STATISTICS
  12. 12. 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 Member Secretary. -Discussions are kept secret. -The important findings are communicated to concern department to take remedial action.
  13. 13. 2. MEDICAL RECORD -All the junior staff (Residents) to be trained and retrained how to fill up the medical records. -All the medical records must be complete on all aspects before sending to record department. -Records to be properly tied up, coded and indexed month wise/ disease wise for easy retrieval. -A complete and correct medical record is the back bone of medical audit. 3. Hospital operational statistics (a) Hospital resources : Bed compliment, diagnostic and treatment facilities, 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 and mortality statistics, average length of stay, Hosp. infection rate
  14. 14. 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
  15. 15. STAGE 1: PREPARING FOR AUDIT USERS INFORMATION PLANNING SELECTING A AUDIT TOPIC DEFINING THE PRIORITISE PURPOSE AUDIT
  16. 16. 1. USERS INFORMATION 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 -genuine collaborators -sources of data
  17. 17. 2. SELECTING A TOPIC -starting point -careful thought and planning - There seems little point in trying to audit a rare condition, with a medical intervention with an insignificant outcome -Try to select topics directly influencing quality of care
  18. 18. 3. MEASURE FOR PRIORITISE Is the topic concerned is of high cost, or risk to staff or users? Is there evidence of a serious quality problem? ( for example patient complaints or high infection rates?) Is there a potential for deviating from or pertinent to national policy initiatives? (for example systematic reviews or national clinical guidelines? ) Is the topic a priority for the organisation? Is good data is available to compare standards?
  19. 19. 4. DEFINING THE PURPOSE -purpose must be established before appropriate methods for audit can be considered. -Once topic selected, purpose defined then suitable audit method can be chosen. -The following objectives may be useful in defining the aims of an audit •to improve the quality •to enhance performance •to increase efficiency •to change procedure •to ensure patient satisfaction •to reduce cost
  20. 20. 5. PLANNING AUDIT Involve ALL the people concern.  Fix time and Plan resources Access the evidence/data Methodology to be followed for data collection Pilot study Audit Report for Action Re-audit All activities should be documented.
  21. 21. STAGE 2: SELECTION OF CRITERIA APPRAISING DEFINING THE CRITERIA EVIDENCE SOURCES OF EVIDENCE
  22. 22. 1. DEFINITION OF CRITERIA -Which area:- -an individual, a team, or an organisation -This can include assessment of the process and/or outcome of care -The choice depends on the topic and objectives of the audit. -They should relate to important aspects of care and be measurable.
  23. 23. 2. SOURCES OF EVIDENCE Systematic 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
  24. 24. 3. APPRAISING THE EVIDENCE Evidence needs to be evaluated to find out if it is valid, reliable and important.  Meeting Aim /objectives Study Methodology  Past Results /conclusions Extent of Applicability to your present study Likely Bias/ causes for concern
  25. 25. STAGE 3: MEASURING LEVEL OF PERFORMANCE HANDLING DATA METHODS OF COLLECTION PLANNING DATA COLLECTION
  26. 26. 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
  27. 27. 2. METHODS OF DATA COLLECTION •Do not try and collect too many items, keep it simple and short, relevant to present study. •Computer stored data, Case notes/Medical Records, •Local Surveys through Questionnaires, Interviews Focus 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 audit 3. Handling data: Ethical implications of decrecy and their responsibilities under the Data Protection Act (1998) when collecting data and presenting results to be kept in mind.
  28. 28. STAGE 4: MAKING IMPROVEMENTS MAKING IMPROVEMENTS CHANGE BY IDENTIFY REMOVE BARRIERS BARRIER
  29. 29. 1. IDENTIFYING BARRIERS TO CHANGE - Fear - Lack of understanding - Low morale - Poor communication - Individual Culture - Doubt of outcome - Consensus not gained
  30. 30. 2. IMPLEMENTING CHANGE systematic approach: •identification of local barriers to change •change culture •Provide support for teamwork •use of a variety of specific methods like delegation and accountability
  31. 31. STAGE 5: SUSTAINING IMPROVEMENT MONITORING REINFORCING AND IMPROVEMENT EVALUATION RE-AUDIT
  32. 32. 1. MONITORING AND EVALUATION: systematic approach to changing professional practice should include plans to: •monitor and evaluate the change •maintain and reinforce the change 2. REINFORCING IMPROVEMENT: •reinforcing or motivating factors by the management . •integration of audit as part of regular practice •strong leadership and high motivation 6. RE-AUDIT: -Review evidence -Measure effectiveness -Decide how often to re-audit - Ongoing process monitoring -Adverse incidents -Significant events audit
  33. 33. TYPES OF CLINICAL AUDIT X -RAY REVIEW STATISCIAL DISEASE AUDIT AUDIT MEDICAL DEATH OBSTETRIC AUDIT CASES AUDIT RANDOM CASE NURSING INFECTION TISSUE/OPERATION AUDIT AUDIT CONTROL CASES
  34. 34. 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.
  35. 35. INDICATORS USED NET DEATH RATE INFECTION RATE < 4% < 2% AVERAGE LENGTH OF CONSULTATION STAY 7 TO 10 DAYS INDICATORS RATE BED OCCUPANCY AUTOPSY RATE 80% < 15% BED TURN OVER ANAESTHETIC DEATH RATE < 1% 6 TO 10 DAYS
  36. 36. 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 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.
  37. 37. 3.AUDIT OF OPERATED CASES In this group patients operated for similar surgical method 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 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) 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 precaution and rectification.
  38. 38. 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
  39. 39. 5. AUDIT OF RANDOM CASES In 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 Skills b) Investigations done, Treatment given, Progress note c) Nursing Care Chart d) 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.
  40. 40. 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.
  41. 41. 7. NURSING AUDIT Nursing audit, is a review of the patient record designed to identify, examine, or verify the performance of certain specified aspects of nursing care by using established criteria. The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect In this case the medical records are examined with respect to type of nursing care given. Special care, Input Output, O2 inhalation, Monitoring record TPR chart, daily nursing note etc. The audit may be retrospective or introspective
  42. 42. EVALUATION OF QUALITY OF CARE QUALITY OF QUALITY OF ART ADMINISTRATIVE TECHNICAL CARE OF CARE. SUPPORT (a) Technical care: can be assessed by adequacy of diagnostic and therapeutic processes. (b) Art of care: Manner and behaviour of provider in delivering care and communication with patient. •A doctor is expected to know not only how to treat a patient but also treat dying patient. (c) Administrative support : Planning, organising & directing all resources for patients care to maximise productivity towards better patient care based on evaluation report.
  43. 43. 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.
  44. 44. 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
  45. 45. PROBLEMS IN MEDICAL AUDIT Lack of organized medical record department. Incomplete record, poor quality maintenance. Fear of action and lack of motivation of medical staff. Ignorance of value of medical audit by hospital staff. Suppression of facts, wrong reporting, Completion of records after death restrict the true value of medical audit.
  46. 46. CONTENTS OF AN AUDIT REPORT Background Literature review Criteria and standards Methods or protocol used Results Recommendations for change Recommendations for further audit
  47. 47. hospiad Hospital Administration Made Easy http//hospiad.blogspot.com An effort solely to help students and aspirants in their attempt to become a successful Hospital Administrator. DR. N. C. DAS
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