Rashid Hashmi ( Atomic Energy Medical Centre, Jinnah Postgraduate Medical Centre, Karachi. )
Shahid Kamal ( Atomic Energy Medical Centre, Jinnah Postgraduate Medical Centre, Karachi. )
Medical audit is an established and distinct entity in the developed countries. It pertains to the critical analysis of the quality of medical care including quality of life and outcome forthe patient, procedures used forthe diagnosis and treatment and the use of available resources. The prime objective of an audit is to improve the standard of care given to the patients. It is described as a cycle composed of several stages. It is a way of improving current performances by deciding on the ideal (setting standard), looking at the real situation (measuring current performance) and finding ways of moving from the real to the ideal (implementing changes)1.
Audit is not an easy task and strict criteria have been laid down for it2. It has to be systematic, orderly and planned. It must be critical and in order to be so it is essential to involve peer review. For any, audit, the first step is the precise definition of the problem which is to be studied. This is followed by the setting of standards which involve extensive review of available relevant literature. Once these basic steps are agreed upon, information is collected and compared with standard using routine statistical methods. The results am then compiled for presentation in meetings and publication. On the basis of the results recommendations are formulated.
Audit should not be confused with the traditional clinical reviews as it uses explicit criteria for measurement with which current practice patterns are compared. It also involves comparison with the practice of peers. Any discrepancies/deficiencies are identified and noted and suggestions are formulated to improve and overcome them. The whole process is recorded and re-audit is done after sometime to see the outcome of the first exercise.
Majority of methods of audits follow a retrospective approach. Two main types of audit most commonly practiced are basic clinical audit and criterion based audit3.
Basic clinical audit is essentially a general review of the through-put and management. With the growing application of computer in the hospitals this type of data is readily available for audit purposes. It involves review of routine statistics and selected adverse patient events e.g., length of hospital stay after laproscopic cholecystectomy or percentage of operations performed by the consultants etc. It also includes review of randomly selected records. Analysis of individual patient records by a senior doctor with an agreed format gives invaluable insight into the objectively selected cases.
Criterion based audit is an analysis of agreed topic which may be carried out by prospective study (which might include a survey of patient satisfaction) or by a retrospective analysis of medical records. This type is commonly practiced in U.S.A., Australia and Netherlands. Selection of topic is the foremost step and is followed by designing of criteria for
screening records. This may involve development of a questionnaire comprising of 10-15 clearly defined questions which can be answered by yes or no. After the formulation of questionnaire suitable cases are identified which are analyzed and results achieved.
Audit, if performed routinely and objectively, can have a significant impact on the overall health sector of the country. In fact countries with efficient health delivery system owes much to the practice of medical audit. A comprehensive audit of health sector can incorporate following different components:
a) Audit of structure i.e., actual facilities available at central, provincial, district levels and lower down. This may include number of beds available and their occupancy rate, type of equipments, availability of staff etc.
b) Audit of process i.e., methods of providing medical care. This may include frequency and turn over in the outpatient department and wards, criteria of diagnosis, use and abuse of available drugs, management approaches etc.
c) Audit of outcome i.e., actual result of management
In Pakistan medical audit is in its infancy and is not a well understood and well acknowledged entity. There are only few hospitals in the country where it is conducted on regular basis. Though in the past few years there have been scores of presentations about audit in symposias and seminars but most of them were simple retrospective studies. Often these were not conducted in a systematic way and without peer review which are the main essence of an audit. Audit involves more than what is being undertaken currently in Pakistan.
It is however, heartening to note that the culture of audit is gradually developing. During the year 1995, three original aiticles were published in the Journal of Pakistan Medical Association4-6. Though all of them were from one hospital, it can nevertheless stimulate others to follow the same. One hopes that in days to come, medical audit will take root and establish itself firmly in Pakistan.
1. Sue, K., Nicholas, L. and Andrew,M. Using computers in clinical audit, Br:Med. 3., 1995;311 :739-42.
2. Heath. D.A., Hoffenburg, R., Bishop, J.M. et al. Medical audit. 3. R. Coil. Physicians Lond., 1980;14:200.201
3. Shaw, CD. Criterion based audit. Br. Med. J., 1990;300:649.651
4. Khan, KS. and Rizvi, J.H. Audit changes clinical practice: Impact on rate of justification ofhysterectomy indication, 3. Pak. Med. Assoc., 1995;45:208-212.
5. Bumey, P.G.J Asthma mortality in.England and Wales. Evidence for a further increase, 1974-84.Lancet, 1986,11:323.6.
6. Flemming, D.M. and Crombie, DL. Prevalence of asthma and hay fever in England and Wales. Br.Med. 5., 1987;294:279.83.