The medical audit is 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’.The audit is a continuous cycle, involving observing practice, setting standards, and comparing practice with standards, implementing change, and observing the new practice. To be meaningful audit procedures must complete this cycle.
Improve Patient Care
The principal aim of the audit is to improve patient care, for example by reducing unnecessary treatment and investigations, preventing iatrogenic disease, and by identifying patients with continuing problems who have not been followed-up. This can be achieved through agreement on methods of treatment of common conditions, adoption of standard policies and regular reviews of the work of departments. The reviews can evaluate whether diagnoses and treatments are appropriate and should identify complications which could have been avoided. Ideally, each unit’s performance should be compared with agreed standards which take into account relevant factors including the social composition of the population, case-mix, provision of unrecognized regional services and constraints on the service. Analysis and comparisons using accepted standards, performance indicators, and outcome parameters then become an important stimulus in identifying areas for learning and for the improvement of patient care. The ultimate goal of an audit process is improved clinical practice, leading to better patient outcomes.
Many complaints by the public refer to poor communications. Inadequate notes and insufficient discussion with patients are recognized problems and are a major factor in complaints which reach the courts. Audits have demonstrated how communication with patients can be assisted by the production of written guidelines for junior hospital staff, by printed information leaflets and by the practice of monitoring the recording of information given to patients. Communication with general practitioners is facilitated by the production of prompt discharge summaries. Some audit systems produce regular summaries as a by-product of data entry, and others monitor the delay in sending letters. The Audit has also identified the value of criteria for patient referral for general practitioners, thus reducing work at outpatients. Monitoring the quality of notes will facilitate the transfer of information to those nurses and doctors who see patients when on call.
The audit can be a form of education, and formal sessions are increasingly being recognized as an essential component of training in clinical skills. Consultants have a key role in postgraduate medical education. Training schemes based on learning by apprenticeship are often inadequate and pressure is incasing for regular appraisal of both trainer and trainee. The audit can make an important contribution to this procedure and is likely to become a requirement for the recognition of training posts. The clinical audit enables surgeons to benefit from peer review and feedback, from which they can maintain confidence in their practice abilities. Case study analysis clearly presents what has happened with patients admitted for care. Possible issues can be identified and alternative practices discussed. Surgeons should be aware of the pattern of their practice and their performance, so adjustments can be made to advance professional development and improve their services to the community.
The clinical audit provides the opportunity to confirm established processes resulting in expected outcomes, but more importantly, highlight potential problems areas within an organization. It involves capturing basic information about the day-to-day work of clinical practice in order to look closely, identify problems, consider and make changes, and monitor progress towards improved patient outcomes. In a climate of resource constraints, the ability of audit to improve cost-effectiveness is attractive. Ineffective care is, by definition, expensive, and precludes the provision of other services. The Audit will identify those areas which can generate cost savings without affecting patient care. Examples might include guidelines for the use of investigations, for the early diagnosis of illness, for standardized policies on drugs and consumables, and the reduction of length of stay by reducing complications.
There is a range of methods which can be used in the performance of the audit. The increasing availability of PCs has made it possible for many more people to analyze data. There is an urgent need for sources of data to be produced in a format in which they can be downloaded. In the cases of hospital data, this could be achieved through direct communications systems. Other data could be made available on compact discs. If the audit is to succeed it must have the full support of management. This will mean that clinicians and management must agree that the prime objective of the audit is to improve patient care, and not to reduce costs regardless of the quality of service. There must also be the recognition that the audit takes time which will hot be available for other activities, and it will require adequate clerical support.