SMCH/HCDS/29: Medical Audit

Quadrant-I

Personal Details

Role Name Affiliation

Principal Investigator Prof. CP Mishra Department of Community Medicine,
Institute of Medical Sciences, Banaras
Hindu University, Varanasi

Paper Coordinator Prof. Najam Khalique Department of Community Medicine,

J N Medical College, AMU, Aligarh

Content Writer Dr. Anees Ahmad Department of Community Medicine,

Associate Professor J N Medical College, AMU, Aligarh

Content Reviewer Prof. Najam Khalique Department of Community Medicine,

J N Medical College, AMU, Aligarh

Description of Module

Items Description of Module

Subject name Social Medicine & Community Health
Paper name Health Care Delivery System
Module
name/Title Medical Audit
Module Id SMCH/HCDS/29
Understanding of standard treatment guidelines and quality issues in health
Pre-requisites care.
To know about purpose, principles, pre-requisites and mechanics of Medical
Objectives Audit.
Keywords Clinical audit, Medical audit, Morbidity audit, Quality improvement.

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Introduction

A good death is not accounted as a single event rather it is seen as a series of events, relationships and
preparation that takes place over time. As a consensus, there is no gold standard for what constitutes a
good death, the definition varies between individuals and therefore quality of care must be discussed
to incorporate the individual patient values and preferences [1]. Medical audit helps in determining
the quality of medical care provided to patients by analyzing the clinical records and hospital services.
It was Mac Eachern who stated, “That financial deficiencies can eventually be met but medical
deficiencies may cost lives & loss of health which can never be retrieved. The aspect of dealings‟ in
medical care, along with examination & verification in a hospital is termed as medical audit”. The
main aim of evaluation of medical care, through qualitative analysis of clinical records, including
analysis of hospital services is a simpler way to look into the meaning of Medical Audit.

Learning outcomes

Upon completion of this module, the reader should be able to:

• Define audit and medical audit
• Pin point the difference between medical audit and clinical audit
• Provide historical perspective of medical audit
• Mention need and purpose of medical audit
• List pre-requisites for medical audit
• Mention principle of medical audit
• Describe different stages of medical audit
• State different type of medical audit
• Mention limitation of medical audit
• Mention importance of research in conducting medical audit
• Mention place of medical audit in modern health care

Main Text

1. Audit and medical audit

1.1. Audit is the process of evaluating data, documents and resources to check performance of
systems that meets specified standards [2]. It is simple tool to find out what you do now; compared
with what you have done in the past, or what you think you may wish to do in the future. It is a
cyclical process of :
• defining standards
• collecting data,
• identifying areas for improvement,
• making necessary changes
• back round to defining new standards.

1.2. Medical audit

Medical audit is a quality improvement process which seeks to improve patient care and outcomes
through systematic review of care against standard criteria and the implementation of change. Medical
Audit is a planned programme which help in monitoring and evaluation of the clinical performance of
all practitionersIt identifies opportunities for improvement, and guides through approaches to make
and sustain those improvements.

DEFINITION: “It is defined as a quality improvement process that seeks to improve medical care and
outcomes through systematic review of care against explicit criteria and implementation of change”.
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(Principles of best practices in clinical audit, The national institute of clinical excellence(2002)

2. Medical audit vs clinical audit

Medical auditis negotiated as the assessment of the clinical care of patients provided by the medical staff
only
Whereas clinical auditis 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’

3. History of medical audit

History of medical audit dates back to 1750 BC: when the 6th king of Babylon, Hammurabi ordered
audits for the clinicians in his kingdom. In the Modern medicine (1853–1855): Florence Nightingale
was the first to conduct clinical audit during the Crimean War. She applied strict sanitary and hygiene
standards that decreased the mortality rates from 40% to 2%. In the 1869–1940: Ernest Codman
became known as the first true medical auditor following his work in 1912 while monitoring surgical
outcomes. Codman's "end result idea" was to follow every patient's case history after surgery and
identify errors made by individual surgeons on specific patients.
In India however, the process is slow and apart from some specified area of maternal mortality or
infant mortality data on medical or death audit is truly lacking. In India in 1961: Report of Mudaliar
committee stressed on encouragement of medical audit in India. India in atrue sense was introduced to
medical audit in 1969. But it became operational only in 2007, after the establishment of National
Accreditation Board for Hospitals and Healthcare Providers (NABH) in 2005.

4. Need and purpose audit

Medical audit is required for maintaining participant and staff safety, for maintaining data quality,
Protecting reputation of staff, host and sponsor, Protecting current and future funding and Improving
quality of the healthcare. It does not involve experimentation as it utilizes data that already exists.

4.1. Need for medical audit

• For Professional accuracy- Health care providers can identify their lacunae & deficiencies and make
necessary corrections to improve their proficiency.

• For Social motives- Safety of public and protection from care that is inappropriate, suboptimal &
harmful can be ensured.

• For Pragmative motives- Patient ’s sufferings and denial of the available services, or injury by
excessive or inappropriate service can be avoided and reduced to a grater extent.

4.2. Purpose of medical audit

Medical audit can fulfill the primary purpose of planning the future course of action. It is required to access
the baseline information through periodic evaluation of achievements and then making comparisons with
a view to improve the services. The nature of such an audit is regulatory and it ensures full & effective
utilization of staff and available services.Medical audits also suffice the purpose of assessing the
effectiveness and efficiency of health programmes & services put into practice [3].

5. Prerequisite for medical audit

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  Hospital operational statistics - Statistical data on the hospital resources like Bed compliment,
diagnostic and treatment facilities, staff available should be obtained beforehand. Hospital
utilization Rates based on Days of care, operations, deliveries, deaths, OPD investigations,
laboratory investigations are to be analyzed and Data for admissions comprising of Information
on patients i.e. hospital morbidity statistics, average length of stay (ALS), operation morbidity,
outcome of operation are to be maintained and obtained as well.
 The procedure of collection and tabulation of hospital statistics should be standardized.
 Primary source of this data is medical records, hence ensuring accurate and completed
medical records are made beforehand.
 Quantitative analysis of all records is made sure to be carried out by a well trained Medical
Record librarian.
 A Hospital planning and research cell should be established at state level which will help in
tabulating and analyzing the data, with further recommendations for improvement purpose.
 Formation of a committee
Medical audit committee should be constitutedof hospital consultants, who are committed to
undertake the Medical audit. The committee should meet once in a month and submit the confidential
report to medical superintendent (MS) [3].

It should be constituted of:

Senior clinical consultant Chairman
Consultants from concerned clinical depts Members
Representative of MS Member
Medical record officer Member Secy.

When a medical audit committee is chosen to audit the records, major departments should be
represented & there should be rotation of members to give various persons an opportunity to
contribute to the programmer. The members of the committee must be experienced physicians who
have good judgment & are frank, fearless, & without prejudices. There must be one Forensic Expert, a
Pathologist and the Doctor essentially among the members of the committee, who was in charge of
the patient during his or her treatment [4].
 Medical record librarian
A trained medical record librarian with a good background of medical knowledge is essential to carry
out the very first step of audit i.e.medical accounting or quantitative case record analysis [5]. If such a
person is not available then , it is considered that an intern or a house surgeon should be able to
supervise & guide the staff to carry out the analysis.
 Medical record
Last, but not the least is the source of information for medical audit, i.e. the medical record
maintained by the hospital. These must be complete & accurate, as analysis or an audit can be no
better than the medical records from which it is compiled.

6. Principles of medical audit

 Health authorities and medical staff should explicitly define their respective responsibilities
for the quality of patient care provided.

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  Medical staff should organize themselves in order to fulfill responsibilities for audit and for
taking action to bring about improvement in clinical performance.
 Each hospital and specialty should have a regular programme of audit in which doctors in all
grades should participate.
 The process of audit should be relevant, objective, quantified, repeatable, and able to bring
about appropriate change in organization of the service and clinical practice of patient care.
 Clinicians should be adequately provided with the resources for medical audit.
 The whole process and outcome of medical audit should be documented with accuracy.
 Medical audit should be subject to evaluation.

7. Stages of medical audit

7.1. Stage 1: Preparing for audit-

• Involving users: Users including genuine collaborators, sources of data are to be taken into
account. The user concerns can be identified from various sources, like:Letters containing
comments or complaints, critical incident reports, individual patients’ stories or feedback from
focus groups, direct observation of care and direct conversations with the service utilizers.
• Selecting a topic: It is the starting point of a medical audit, which requires careful thought and
planning. There is little or no point in trying to audit a rare condition, with a cheap intervention
with a fairly superficial outcome
✓ Tool for prioritizing audit topics questions:
✓ Is the topic concerned of high cost, or risk to staff or users?
✓ Are there evidences of a serious quality problem? for example high rate of patient complaints
or high complication rates?
✓ Is there potential for involvement in a national audit project or national policy initiatives?
✓ Is the topic a priority for the institution?
✓ Are good evidences available to inform standards? for example systematic reviews or national
clinical guidelines?

• Defining the purpose -purpose should be established before appropriate methods for audit can be
considered. Once topic is selected and the purpose is defined then suitable audit method can be
chosen.The following series of verbs may be useful in defining the aims of an audit to improve,
to enhance, to increase, to change, to ensure.

• Planning- Should Involve all the people concerned, time and resources. Access to the evidence,
should be sort out. Methodology should be chalked out. Then piloting should be undertaken to
access the feasibility of the whole process and resources required. Results should be reported
clearly and necessary action required to correct the fallacies should be taken. Planning should
be done for Re-auditing beforehand. Appropriate Data collection instrument should be defined.
All the above steps of planning should be documented.

7.2. Stage 2: Selection criteria

• Defining criteria-This could be an individual, a team, or an organization. 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.
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• Sources of evidence-Systematic methods should be used to gather the records. Good-quality
guidelines, reviews of the evidence, previously use criteria for same purpose can be applied.
Measurement of outcome should be defined prior. The audit team can develop own standards.
Reference to levels achieved in audits undertaken by other professionals can also be useful.

• Appraising the evidence- Evidence needs to be evaluated to find out if it is valid, reliable and
important. Aim /objectives, Methodology, Results/conclusions, should be analyzed and whether
applicable to your patient group, should be critically appraised. Bias and causes for concern should
also be dealt appropriately.

7.3. Stage 3: Measuring level of performance -

• Planning data collection-the data collected should be precise, essential. User group to be
included ideally for data collection process.

▪ Examples
1.All children under 16 years diagnosed with asthma and registered with the primary healthcare
team.

2. All women receiving treatment for breast cancer in JNMC

▪ Methods of data collection-Do not try and collect too many items and data should be kept simple
and short. Computer s should be used to store data. Case notes/Medical Records, Surveys,
Questionnaires, Interviews, Focus Groups, Prospective recording of specific data, all these
methods can be applied. Compare performance against the criteria. Keep focused on the
objective of the audit.
▪ Handling data - Ethical implications and their responsibilities under the Data Protection Act
(1998) when collecting data and presenting results should be followed strictly.

Figure 1.Stages of Clinical Audit

Assessed from: http://image.slidesharecdn.com/clinical-auditpresentation-1232702688840564-
2/95/clinical-audit-presentation-16-728.jpg?cb=1232681188

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7.4. Stage 4: Making improvements-

 Identifying barriers to change: Fear, Lack of understanding, Low morale,Poor

communication, Culture, Pushing too hard, Consensus not gained all these could act as
potential barriers in improving the lacuna in the health services. Appropriate steps should be
taken to identify such barriers and to tackle them.
 Implementing change: Asystematic approach through identification of local barriers to
change, acquiring support of teamwork and use of use of a variety of specific methods can
help in implementing the desired changes.

7.5. Stage 5: Sustaining improvement-

▪ Monitoring and evaluation:Systematic approach to bring about a change in professional practice
should include plans to monitor and evaluate the change, maintain and reinforce the change.
• Re-audit:Review evidence,Measure effectiveness, Decide how often to re-audit, Ongoing process
hasto be monitored and adverse incidents should be prevented.
• Maintaining and reinforcing improvement:Reinforcing or motivating factors built in by the
management, integration of audit, strong leadership ETC will help in re-enforcing the desired
improvements.

8. Types of medical audit

 Morbidity audit: It is a method of doing medical audit of a group of cases suffering from a
specified disease category. Findings are compared with predetermined normal values and
standards guidelines of care framed by medical staff for this disease. It is done ward/unit
wise.
 Audit of operated cases: under this method, a group of patients who have been operated for a
similar surgical condition are analyzed. Again a group of surgeons is asked to lay down the
desirable norms and standards. The pathological reports of the tissues during operation are
emphasized on. Pathological diagnosis is an important parameter for tallying with the percentage
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 of the preoperative diagnosis. Investigations in this type of audit are required on type of
antibiotics used, the number of postoperative infection, the anesthesia and operation notes.

 Audit of obstetric cases: Done in more or less on the same line as in operated cases. Only
difference is here percentage of C/S, forceps application, MMR, NMR etc. are the important
parameters.

 Audit of death cases in the hospital (mortality review): deaths taking place after 48 hrs. of
admission to the hospital are normally subjected to a review by a committee. It is 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

 On spot medical audit: 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.

9. Limitations of medical audit

Commitment, participation and seriousness for the audits play the part of major loopholes in a medical
audit in ourcountry. Audits in Indian scenario are done only to fulfill the requirement of various
accreditation or other external agencies and are still more or less considered as an obligation rather than
for the improvement of hospital processes. Low number of auditors is also a grave concern for hospital
auditing in India [7]. Despite the clear-cut methods described in official publications, the techniques for
doing this are imperfect and are not standardized. Another limitations of medical audits are that they can
only assess limited aspects of the technical quality of care because they are retrospective and dependent
entirely on information contained in the record.

10. Audit vs research:

Audit:- are we doing the best thing in the best way?

An audit measures current practice against specific standards. They are never experimental. They use
data in existence by virtue of practice. May require ethical approval. Aims to improve delivery of
patient health care.

Research-What is the best thing to do/the best way to do it

Provides sound basis for medical audit.Involves experiments and trials.Uses detailed data collection
methods. Needs ethical approvals well as registration.Aims to add the found information to body of
scientific knowledge.

11. Place of medical audit in modern healthcare

Today, health has become a priority for Indians due to growing individual income. Patients put a lot
of value to the quality of healthcare provided by the hospitals. In recent years, patients have an array
of hospitals to choose from the mushrooming hospitals. So there is a stiff competition among the
hospitals to maintain their standards and improve them as and when required, moreover number of
malpractice and negligence suits against the providers of healthcare are also increasing [8]. The
moment a new patient is admitted to the hospital puts additional pressure on organizations and
practicing physicians to evaluate the quality of care provided. Hospitals have to create patient care
and safety impact, through processes and infrastructure [9]. The process of audit ensures consistency
in delivery of clinical and non-clinical services; it also addresses the habit of continual improvement.
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
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hospital systems and medical fraternity as an improvement initiative rather than a fault finding
mechanism.

Summary
It should be remembered that patient care includes both objectively or subjectively examined
elements. The measurement of the objective elements can be made by statistical documentation &
analysis to serve as a point of departure from which qualitative judgment can be made, where as the
subjective elements can be accessed by qualitative judgment through clinical evaluation. Stimulation
for improvement of clinical services, professional education, hospital administration & better patient
care can be provided only by continuous evaluation process. Thus Medical audit, when practiced
religiously with strict guidelines and recommendations can go long way in improving the quality of
patient care in our hospitals, which at present is far below the expectation of the community.

References:
1.Somnath Das, Surendra Kumar Pandey, Prabir Chakraborty.Medical Audit and Death Audit. J
Indian Acad Forensic Med, 32(4); 369-70.

2. Paul J Sanazaro. Medical Audit, Continuing Medical Education and Quality Assurance.West J Med
125:241-252,Sep 1976.

3. Undertaking a clinical audit project: a step-by-step guide e book chapter 2.

Available from :www.rcpsych.ac.uk/pdf/clinauditChap2.pdf

4. Francis C. Hospital administration selected reading in hospital administration: New Delhi: India
Hospital Association Delhi; Jan 1990.

5. George M. The Hospital Administration. New Delhi: Jaypee; 2003.

6.Sarkharkar B, Principles of hospital administration and planning. Jaypee brothers medical

publishers.1999.

7. Srinivasan A. Managing modern hospital by Medical audit and its administrations. New
Delhi\London: Response books. 2005

8.Sharma Y, Mahajan P. Role of Medical Audit in health Care Evaluation. JK science.1999;1(4).193-

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9. Ashwini NS, Vemanna NS, Vemanna P. The Basics in Research Methodology: The Clinical Audit.
JNMR 2011;5(3).679-82.