1. MEDICAL AUDIT
DR. N. C. DAS

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. 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. TYPES OF AUDIT
AUDIT MAY BE INTERNAL OR EXTERNAL
MANAGERIAL/
ORGANISATIONAL
MEDICAL AND
FINANCIAL
CLINICAL

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. METHODS USED IN AUDIT
Direct observation
Checklists
Documentation/records audit
Questionnaires
Interviews
Clinical Case review

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. 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. 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. 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. PRE-REQUISITE FOR CLINICAL AUDIT
CLINICAL
AUDIT
MEDICAL AUDIT WELL ORGANIZED
COMMITTEE MEDICAL RECORD
HOSPITAL
STATISTICS

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. 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. 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. STAGE 1: PREPARING FOR AUDIT
USERS
INFORMATION
PLANNING SELECTING A
AUDIT TOPIC
DEFINING THE PRIORITISE
PURPOSE AUDIT

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. 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. 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. 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. 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. STAGE 2: SELECTION OF CRITERIA
APPRAISING
DEFINING
THE
CRITERIA
EVIDENCE
SOURCES OF
EVIDENCE

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. 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. 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. STAGE 3: MEASURING LEVEL OF
PERFORMANCE
HANDLING
DATA
METHODS OF
COLLECTION
PLANNING
DATA
COLLECTION

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. 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. STAGE 4: MAKING IMPROVEMENTS
MAKING IMPROVEMENTS
CHANGE BY
IDENTIFY
REMOVE
BARRIERS
BARRIER

29. 1. IDENTIFYING BARRIERS TO CHANGE
- Fear
- Lack of understanding
- Low morale
- Poor communication
- Individual Culture
- Doubt of outcome
- Consensus not gained

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. STAGE 5: SUSTAINING IMPROVEMENT
MONITORING
REINFORCING
AND
IMPROVEMENT
EVALUATION
RE-AUDIT

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. CONTENTS OF AN AUDIT REPORT
Background
Literature review
Criteria and standards
Methods or protocol used
Results
Recommendations for change
Recommendations for further audit

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