Medical errors such as incorrect medication administration, incorrect procedure implementation, or inconsistencies in medical documentation and coding can impact safety, patient satisfaction, and financial losses for hospitals. This is why regular medical audits are crucial.
Medical audits are not evaluations used to find fault with medical staff. Rather, they are used to maintain the quality of healthcare services. Therefore, professional quality monitoring and control should be conducted regularly to maintain its quality.
What is a Medical Audit?
A medical audit is a process of evaluating the quality of medical services to patients through patient medical records carried out by medical workers.
Medical audits are conducted to maintain the quality of healthcare providers. Therefore, professional quality monitoring and control are carried out through the audit process. This audit includes quality monitoring, such as morning report, difficult cases, room rounds, death cases, up to journal reading.
The audit results will be a means of follow-up which will be realized through short training (short course), continuing education activities, or additional authority education.
Based on the Regulation of the Minister of Health of the Republic of Indonesia Number 755 of 2011 concerning the Implementation of Medical Committees in Hospitals, the media audit process takes place in several stages as follows.
- Topic selection
- Establishing standards or criteria
- Determination of the number of cases or samples to be audited
- Comparing standards or criteria with service delivery
- Conducting case analysis that deviates from standards and criteria
- Implementing fixes
- Planning a re-audit
Differences between Medical Audit and Clinical Audit
| Aspect | Listen to the media. | Clinical Audit |
|---|---|---|
| Purpose | Improving the quality of services, ensuring standard practices, providing educational facilities for medical personnel, identifying and mitigating risks in services, and ensuring compliance with regulations. | Ensuring care meets the highest evidence-based standards, assessing healthcare professionals' adherence to clinical guidelines, and changing practices to improve patient safety and effectiveness. |
| Focus | Evaluation of doctor's services. | Assess service quality comprehensively. |
| Executor | Medical professions, such as doctors. | The audit team consists of medical, nursing and health workers. |
| Relatedness | One of the components in clinical audit. | The big umbrella that covers medical audits. |
See also: Medical Audit: Types, Scope, Benefits, and Examples of Implementation
Types of Medical Audits
1. Internal Medical Audit
An internal medical audit is an audit conducted by individuals within a healthcare unit. The purpose of this audit is to evaluate an organization's internal controls, risk management processes, and operational efficiency.
Thus, auditors focus on reviewing internal systems, processes, and procedures to identify weaknesses, inefficiencies, and areas that need improvement.
2. External Medical Audit
Meanwhile, an external medical audit is an audit conducted by an independent external individual. Generally, external audits are conducted annually. Their purpose is to provide an objective, impartial evaluation of a healthcare unit's records.
Scope of Medical Audit
- Compliance with standards – auditor. ensure services comply with SOP or Standard Operating Procedures and applicable medical standards.
- Quality of service – auditors evaluate the efficiency, effectiveness and safety of medical procedures and the management of drugs and medical equipment.
- Patient safety – auditors assess how reliable the health service unit is in preventing adverse events and improving patient safety.
- Medical documentation – auditors assess the completeness, accuracy, and timeliness of filling out medical records.
- Clinical process – auditors review important cases such as deaths, difficult, rare cases, and cases with lawsuits to ensure that health care is provided safely and according to standards.
- Management and finance – auditors evaluate billing, code of ethics compliance, cost optimization, and cost transparency to ensure fair economics.
- Patient satisfaction – auditors assess the level of patient satisfaction with the services provided.
- Systems and Human Resources (HR) – auditors assess whether facilities are used optimally, information systems are working efficiently, and health workers are qualified and competent in their fields.
Benefits of Medical Audit
- Promoting transparency, integrity and accountability in the delivery of health services.
- Identify and correct errors or discrepancies in medical documentation.
- Reduce the risk of misdiagnosis and inappropriate treatment.
- Reduce the risk of legal and financial consequences.
- Protecting healthcare organizations from penalties.
Medical Audit Example
To provide a clear illustration of the medical audit process in a healthcare unit, here is an understandable example.
1. Choose a Topic
The medical committee designated the topic of "completeness and accuracy of inpatient medical records" as the audit area. The goal was to ensure that no medical records were late in being completed.
2. Setting Standards
The standards used refer to the Minister of Health's Regulation on Medical Records and hospital SOPs which require medical resumes to be completed within 24 hours of the patient's discharge.
3. Observing Practice
To achieve this goal, the audit team reviewed 50 inpatient medical records from the past month. The auditors also recorded the time and completeness of the medical resumes completed by the attending physician.
4. Comparing Actual Practices with Standards
After the auditors conducted a comparison, the audit results showed that only 70% of medical records were completed within 24 hours. The remaining 30% were completed late or incompletely, particularly in the final diagnosis and follow-up plan sections.
5. Implementing Improvements
To optimize the completeness and accuracy of patient medical records, the auditor has provided a number of recommendations to healthcare providers.
They followed up by re-socializing the SOP for filling out medical records, implementing automatic reminders through the electronic medical records system, and establishing regular monitoring by the medical committee.
Closing
Medical audits play a crucial role in maintaining quality of care. This process helps healthcare facilities ensure compliance with clinical standards while simultaneously improving the quality of care.
However, in practice, audits are often hampered by manual documentation, time constraints, and difficult follow-up monitoring. Therefore, healthcare providers need not only reliable and independent auditors but also software that can support a smooth audit process.
If your company is planning to conduct a medical audit, use Audithink audit application which can facilitate planning, implementation, reporting, and monitoring. This audit application allows companies to monitor in real time and save time on report generation. Schedule a demo now or contact our team for further consultation.
