Medical audit By Sr. CMO Safdarjung Dr. Anjan Prakash

Success of medical audit depends on its implementation
Dr Anjan Prakash

During the last few years, a number of important developments have had a profound impact on the delivery of healthcare in India. Perhaps the most important of these to clinicians, administrators and patients, has been the change in society’s attitude towards the quality of care that a patient expects a hospital to deliver. This increased emphasis on the provision of quality healthcare stems, in large part, from the increasing number of malpractice and negligence suits against the providers of healthcare. This also puts additional pressure on organisations and practising physicians to evaluate the quality of care provided.

Thus, while there is a general agreement on the need of evaluating the healthcare provided and to conform to the regulations requiring the monitoring of this care, there is little agreement as to what constitutes quality care or what is the form that evaluation and/or monitoring should take. There are enormous pressures the health and hospital administrators have to deal with, like political, financial and medical emergencies. Within this framework medical professionals are striving for continued improvement of their performance and the highest standards of excellence.

Self-evaluation of any degree and of any value is improbable and therefore evaluation by audit and peer review is more likely to achieve its objectives. Medical audit is an important component of quality assurance, which in turn is an essential part of any management process. Though the present system of evaluating quality is primitive, non-systematic and episodic, its theory and techniques are reasonably well developed. It is the implementation that is not proper. For the implementation to be proper certain pre-requisites must be met with before starting to evaluate the medical care provided by the hospital. There should be set standards and the criteria that are outlined should also be met with. It should be established as to who will evaluate the services provided and how often will it be done. Also qualitative and quantitative assessments have to be made.

Medical audit is this professional review of services provided by the hospital against given standards. It is defined as the retrospective evaluation of quality of medical care through the scientific analysis of medical records.

The term quality as used in the above definition refers to the degree of conformity with standards, with the best of medical knowledge and with accepted principles and practices. The phrase medical care is used in a restrictive sense to include only those elements of care which are provided by, or under specific direction of the physician. The evaluation is carried out by matching the procedures against the approved standards, which are laid down on the basis of medical knowledge that provides us with the information about what should be done in order to achieve the best results.

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. It is being increasingly felt that while on one hand quantitative development is an important pre-requisite for ensuring accessibility of services, another equally essential requisite is the right quality of services. The evaluation of quality of patient care in hospitals through medical audit has assumed significant importance because it provides valuable feedback to the administrators and to the clinicians who are responsible for efficient and effective running of hospital services.

There are inherent difficulties in medical audit but the aim is to evaluate the quality of medical care to maintain the standard of excellence and improve the standards that fall below the accepted levels.

It is in conformity with the traditions of hospitals and ethos of healthcare that the institutions should maintain high standards of patient care thereby taking a lead in the latest revolution in the healthcare delivery system. They can initiate by forming a medical audit committee that lays down the evaluation procedures. The evaluation procedures can be random analysis of case records and hospital performance indicators like average length of stay, bed occupancy rate, bed turnover rate, infection rate, gross and net death rates, etc.

In order to facilitate the evaluation by the Medical Audit Committee, the clinical faculty should be advised to develop pre-determined acceptable norms, with respect to common diagnoses handled under their specialties. Deviations from these norms will then be easily detected. In some of the major hospitals, the general specialties of surgery, obstetrics and gynaecology and super-specialties particularly, gi surgery, CTVS, paediatric surgery and orthopedics have developed their own norms for the diagnostic group in terms of investigation schedule, clinical management and antibiotic practices.

As regards medical specialties like general medicine, dermatology, paediatrics and psychiatry no established norms for any disease category are known to exist. The clinicians concerned have an explicit view that such norms in their specialty cannot be possibly adopted as a routine. However, in contrast to this, a few hospitals can be found where some of the medical specialties like, gastroenterology; endocrinology, haematology have such norms in existence.

The foremost point expressed by the clinicians is that a dynamic science like medicine cannot possibly have standardized norms for treatment and management of any clinical disease. So, the working norms for disease groups can be made available. They can later be changed from time to time depending on the scientific advancement and discoveries. Such available norms can also be adapted rather than adopted. The clinicians and surgeons have to develop the norms of medical or surgical practice particularly for medical audit individually and not by any outside agency. Norms for diagnostic groups like GI bleeding; gall bladder diseases and for procedures like LSCS; hysterectomy, cardio-vascular surgery, joint replacement surgery are available at many hospitals, based on tome tested practice and development of science and newer antibiotics and diagnostic procedures.

The basic norms for introduction of medical audit like improved support services, availability of material supplies, strict disciplinary authority to junior clinical staff and autonomy of professional practice are a must before any sincere effort of introducing medical audit in a hospital is made. It is important to recognize that the implementation of medical audit is fundamentally an exercise in the management of change. The success of medical audit will depend on how it is implemented. Given the complexity of the evaluation, it is not unreasonable that full implementation might encompass a number of stages or phases and several years of work. The key to the entire process, therefore, is the management leadership to begin with and perseverance to follow it in a sensitive way.

(The author is sr. chief medical officer, Safdarjang Hospital, New Delhi. The article is an excerpt from her book Medical Audit)