Quality Audit and Evaluation of health Care Services

Chapter 6

Objectives

• After going through this chapter, you will be able to understand:– Understand meaning of medical audit,– Awareness of audit process,– Acquainted with the various audit methods,– Conceptualize of hospital performance evolution.

Medical Audit

• One of first Medical audit was undertaken by Florence Nightingale during the Crimean War of 1853—1855.

• On arrival at the medical barracks hospital in Scutari in 1854, Nightingale was shocked by the unsanitary conditions and high mortality rate among injured or ill soldiers.

Medical Audit

• She and her team of 38 nurses applied strict sanitary routines and standards of hygiene to the hospital and equipment; in addition, Nightingale had a talent for mathematics and statistics, and she and her staff kept meticulous records of the mortality rates among the hospital patients.

Medical Audit

• Another notable figure who advocated medical audit was Ernest Codman (1869—1940). 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 surgeon on specific patients.

• Codman’s work anticipated contemporary approaches to quality Monitoring and assurance, establishing accountability, and allocating and managing resources efficiently.

Medical Audit: Definition

• Medical audit is a process that has been defined as “a quality improvement process that seeks to improve patient (Customer) care and outcomes through systematic review of care against precise criteria and the implementation of change”.

• The key component of Medical audit is that performance is reviewed (audited) to ensure that what should be done is being done, and if not it provides a framework to enable improvements to be made.

Pre-requisite of Medical Audit

• Medical audit is also called as clinical audit. Medical audit is good tool for evaluation of the quality of health care.

• Statistical data collected during day to day activities and by internal and external audit teams are very important. Collected data is analyzed with the help of various tools to get exact status of the health care unit.

• Analyzed data is further useful to take corrective actions and implement the continual improvements of the health care unit under audit / evaluation activity.

Process of Medical Audit

• Medical audit can be described as a cycle. Within the cycle there are stages that follow the systematic process of establishing best practice, measuring against criteria, taking action to improve care, and monitoring to sustain improvement. As the process continues, each cycle desires to a higher level of quality.

Process of Medical Audit

Identification of problems

Set criteria and standards

Observe practice data collection

compare performance

with criteria and standards

Implementation of changes

Process of Medical Audit

• Identify the problem /issue: – This involves the selection of a topic or issue to be audited,

and is likely to involve measuring adherence to health care processes that have been shown to produce best outcomes for customer.

– Selection of an audit topic is influenced by factors including:• Areas where problems have been encountered in practice,• What patients & public have recommended that to be review,• Where there is a clear potential for improving service delivery,• Areas of high volume, high risk or high cost, in which

improvements can be made.

Process of Medical Audit

• Define criteria & standards: – Decisions regarding the overall purpose of the audit, either

as what should happen as a result of the audit, or what question you want the audit to answer, should be written as a series of statements or tasks that the audit will focus on. Collectively, these form the audit criteria.

– These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively.

Process of Medical Audit

• Data collection– To ensure that the data collected are precise, and that only

essential information is collected, certain details of what is to be audited must be established from the outset. These include the user group to be included, with any exceptions noted, the healthcare professionals involved in the users’ care, and the period over which the criteria apply.

– Sample sizes for data collection are often a compromise between the statistical validity of the results and pragmatically issues around data collection.

Process of Medical Audit

• Compare performance with criteria and standards: – This is the analysis stage, whereby the results of the data

collection are compared with criteria and standards. The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons why the standards weren’t met in all cases.

– These reasons might be agreed to be acceptable, i.e. could be added to the exception criteria for the standard in future, or will suggest a focus for improvement measures.

Process of Medical Audit

• Implementing change– Once the results of the audit have been published and

discussed, an agreement must be reached about the recommendations for change. Using an action plan to record these recommendations is good practice; this should include who has agreed to do what and by when.

– Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its completion.

Process of Medical Audit

• Criteria Development– The scenario has changed immensely with these regular

audits, today with the rapidly increasing of the hospitals and growing individual income, health has become a priority for Indian citizens.

– Indian patients today put lot of value to quality of healthcare providers by the hospitals. Hospitals have to create patient care and safety impact, at the moment a patient is admitted to the hospital through processes and infrastructure.

Different Types of Hospital Audits

• A quality improvement is a process that seeks to improve patient care and outcomes through systematic review of care against determined criteria and the implementation of change.

• Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against determined criteria.

• Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in health care services.

Different Types of Hospital Audits

• Various types of hospital audit are standard base, medical etc. as explained below.– Standards base audit • A cycle which involves defined standards, collecting data to

measure current practice against those standards, and implementing any changes deemed necessary.

– Adverse occurrence screening and critical monitoring• This is often used to peer review cases which have caused

concern or from which there was an unexpected outcome.

Different Types of Hospital Audits

• Various types of hospital audit are standard base, medical etc. as explained below.– Peer review• An assessment of the quality of care provided by a clinical

team with a view to improving clinical care. Individual cases are discussed by peers to determine, with the benefit of hindsight, whether the best care was given.

– Patient surveys and focus• These are methods used to obtain users/patients views about

the quality of care they have received

Techniques Used in assessment and audit

• The clinical governance lead is responsible for ensuring that there is a clinical audit program within local reliance, and that this reflects national audit priorities.

• The clinical governance lead ultimately retains accountability for clinical audit, but may choose to delegate this role to another, the clinical audit lead.

• At a local level this individual will then be responsible for creating a clinical audit Strategy, setting audit priorities, agreeing the audit program, implementing the strategy and implementing the audit program.

Techniques Used in assessment and audit

The six supports of clinical governance are:

Clinical Effectiveness,Research & Development,Openness,Risk Management,Education & Training,Clinical Audit.

Quality Strategies and Sectional Interest

• Discontent with the high cost and variable outcome of health care has led to a number of initiatives in public policy, finance, and organization of care. All in an effort of measure, control, and improve the value care and to increase the accountability of health care providers to the public and to insures. Some important areas are covered in the next few slides.

Quality Strategies and Sectional Interest

• Health care infrastructure– Discontent a lesser amount of the care providers ratio and

increase in ratio of decease, there is need of multi-fold increase of health care infrastructure.

• Awareness program– Provider of care must arrange the health care awareness

programs, and educate society.• Utilization review– Care providers must justify to insurers their choices to use

expensive tests, surgery, specialty referrals

Quality Strategies and Sectional Interest

• Level of health Care Quality– Major trends toward better quality of care are now well

underway in health care. Integrated delivery systems, more sophisticated information system, and capitates payment are all helping to focus energy on improvements especially in to waste reduction.

– Better informed about the performance of health care organizations, consumers and payers are beginning to make their choices about where to receive care based on technical and service quality characteristics, as well as on price.

Quality Strategies and Sectional Interest

• Quality Control in Health Care– Senior health care leaders

mainly seek to assure quality through accreditation of facilities and people, through periodic external and internal reviews against standards, and through the study of unusual events and complications.

– For the most part, more formal statistical methods for quality control are not in evidence even decades after they have become conventional in many industrial settings.

Evaluation of hospital Performance

• Implementation of QMS in health care management required huge amount of efforts. Implementing such a major program with commitment of so much of resources, Management will like to know the actual outcome of the efforts taken in to the program in terms of set goals and objectives and required corrective actions to achieve the same.

• Evaluation of the successful execution of health care QMS is through a mechanism of statistical, audit, customer survey and external evaluation methods.

Evaluation of hospital Performance

• Aim of Evaluation– Evaluation of various processes like planning, monitoring,

impact analysis, economic efficiency and marketing and public relation is essential. Aim of evaluation of these processes is explain below in brief.

– Planning: The idea behind planning evaluation is that it is possible and necessary to evaluate the process, not only the outcome.

Evaluation of hospital Performance

• Monitoring – Monitoring evaluation provides a systematic assessment of

whether or not a project is operating as per its design and whether or not it is reaching the target population. If it deviates from their original intentions much care must be exercised in interpreting the results from the evaluation study.

• Impact analysis– Impact evaluation is the phase most commonly thought of

with regard to evaluates. Impact evaluation gauges the extent to which a project causes change in the desired direction.

Evaluation of hospital Performance

• Area of Evaluation– Evaluation of top management of the hospital ¡s the

important way to ensure that it understands the performance expectations and receives feedback.

– The Results evaluation ¡s of the most interest to the business leaders, while the other three evaluations (performance, learning, and motivation) are essential to the learning designers for planning and evaluating their learning processes

Evaluation of hospital Performance

• Area of Evaluation– Level 1: (Results) Results or impact measures the

effectiveness of initiative. • Although it is normally more difficult and time consuming to

perform than the other three levels, it provides information that ¡s of increasingly significant value as it proves the worth of a learning and performance process.

Evaluation of hospital Performance

• Area of Evaluation– Level 2: (Performance) • This evaluation involves testing the learner’s capabilities to

perform learned skills while on the job. These evaluations can be performed formally (testing) or informally (observation). • It is important to measure performance because the primary

purpose of learning in the organization ¡s to improve results by having its people learn new skills and knowledge and then actually applying them to the job.

Evaluation of hospital Performance

• Area of Evaluation– Level 3: (learning) • This is the extent to which learners improve knowledge,

increase skill, and change attitudes as a result of participating in a learning process. • The learning evaluation normally requires some type of post

testing to ascertain what skills were learned during the process and what skills they already had.• Measuring the learning that takes place is important in order

to validate the learning objectives.

Evaluation of hospital Performance

• Area of Evaluation– Level 4: ( Motivation ): • Assessment at this level measures how the learners perceive

and react to the learning and performance process. This level is often measured with attitude questionnaires that are passed out after most training classes. • Learners are often keenly aware of what they need to know

to accomplish a task. If the learning process fails to satisfy their needs, a determination should be made as to whether it’s the fault of the learning process design or that the learners do not perceive the true benefits of the process.

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Chapter 6