INTRODUCTION
During the last few years, a number of important developments have had a profound impact on the delivery of health care in India. Perhaps the most important of these to clinicians, administrators and patients, has been the change in society’s attitudes towards the quality of care that a patient could expect a hospital to deliver. This increased emphasis on the provision of quality health care stems, in a large part, from the increasing number of malpractice and negligence suits against the providers of health care. This also puts additional pressure on the health care organisations and the practising physicians to evaluate the quality of care provided
Thus, while there is a general agreement on the need of evaluating the health care provided and to conform to the regulations requiring the monitoring of this care, there is a little agreement as to what constitutes quality care or what form evaluation and/or monitoring should take. There are enormous pressures on the health and hospital administrators to deal with a large number of emergencies: political, financial and medical. Within this framework medical professionals are striving for continued improvement of their performance and the highest standards of excellence. Self evaluation of any degree and of any value is improbable and therefore evaluation by audit and peer review is more likely to achieve its objectives. Medical audit is one component of quality assurance and quality assurance is an essential part of any management process.
According to Avedis Donabedian1: Professor of Public Health at the University of Michigan, “we have granted the health professions access to the most secret and sensitive places in ourselves and entrusted to them matters that touch on our well being, happiness and survival In turn, we have expected the professions to govern themselves so strictly that we need have no fear of 2exploitation or incompetence. The object of quality assessment is to determine how successful they have been in doing so; and the purpose of quality monitoring is to exercise constant surveillance so that departure from standards can be detected early and corrected.”
But, how is quality measured? Are there any procedures or norms or any rational methods which can qualify a hospital to be of a higher quality than another? In the words of Mackillop1:
“Primitive is perhaps the best word to describe the present state of the art of quality assessment. The analysis of one chart by an individual member of a medical audit committee parallels the work of an individual artisan before the industrial revolution. The failure of this method to attain quality control is obvious. Many articulate spokesmen for the health care field acknowledge that hospital medical staff activities to ensure consistent quality to maintain quality control have not been successful.
Non systematic is another descriptive term for the present state of the art. When medical care is evaluated, it is done on an individual, random, episodic basis. The results contribute little to continuing medical education, quality of patient care, and quality control of medical practice.
Episodic is another word that may be used to describe the present process of evaluating medical care in most hospitals. The episodic nature of the medical audit flows of necessity from the episodic nature of medical care. Physicians, sociologists and representatives of many other disciplines have talked long and often about the nature of today’s medical care, which is episodic, crisis oriented and disease oriented. Those concerned with the nature of the evaluation of such care find themselves describing the review process in the same terms that those who describe the actual process of care use.”
Though the present system of evaluating quality of medical care is primitive, non-systematic and episodic, its theory and techniques are reasonably well developed. It is the implementation that is not proper. For the implementation to be proper certain pre-requisites must be met with before starting to evaluate the medical care provided by the hospital. It should be established as to who will evaluate the services provided; how often will it be done and most important is that the care provided will have to be evaluated against some set standards and criteria which have to be set in advance. 3Qualitative and quantitative assessments of the medical care provided will have to be made vis-a-vis predetermined standards and criteria. It is a basic prerequisite to develop some appropriate standards, criterion and guidelines as a tool for evaluation and to ensure that the basic requirements for medical audit are met with before it is fully implemented.
Medical audit is a professional review of services provided by the hospital against given standards. It is defined as the retrospective evaluation of quality of medical care through the scientific analysis of Medical Records.
Medical audit is far more important to a Hospital than financial audit. Financial deficits can be met with eventually but medical deficiencies can cost lives, loss of health and agony which can never be retrieved.
It is being increasingly felt that while on one hand quantitative development is an important pre-requisite for ensuring accessibility of services, an equally essential requisite is that the services provided are of the right quality. The evaluation of quality of patient care in hospitals through medical audit has assumed significant importance because it provides valuable feedback to the administrators and to the clinicians who are responsible for efficient and effective running of hospital services, and to whom the patient looks with all expectations and hopes. The patient care services have to have a wholistic as well as a holistic approach. It may be relevant to quote Dr KA Dinshaw, Director, Tata Memorial Hospital, Mumbai who said in a recent interview, “when a patient comes for treatment we are not treating the cancer Mrs. A. has, we are treating Mrs A who has cancer.” These aspects have to be given all importance while evaluating the patient care services.
In the following chapters an attempt has been made first to lay out a conceptual foundation for medical audit and then to build on that foundation by constructing a general process to be used for developing criteria for evaluation of medical care in a hospital. It is important to recognise that the way medical audit is launched has a lot to do with the results it achieves and this justifies the need for specifications and pre-requisites to medical audit.
Our country has a unique place in the health services arena. It was 2000 years ago that Charaka in his famous Ayurvedic Treatise: “Charaka-Samhita” documented his wisdom and today we are proud to have centres of excellence in all aspects of health sciences. 4 The health services and our hospitals have grown enormously over the years. During their expansion and growth many of our hospitals and institutions have been making continuous efforts so as not to loose sight of the high quality of performance expected from them. In such hospitals and institutions wherever there has been growth without dilution of standards it has been, in no small measure, due to the dedicated efforts of clinicians and staff of those hospitals and their endeavour to keep pace with the clinical and technical developments. Many such centres of excellence are known to provide the level of international quality health care by inducting the latest technologies and highly talented specialists from various medical/surgical disciplines. Implementation of medical audit will be their noblest experiment because of the salutary influence it will have on the patient care. The central tenet of medical audit is that patients in a hospital should receive the best care modern medicine has to offer.
Today, our profession has numerous problems. The physician has been always referred to as the healer of the patient and this concept must remain a central tenant. The highly advanced technology, the data of the Genome Project have their own challenge and their major challenge lies where they interface with our clinical skills and our ethics. It is the clinical expertise which will continue to endeavour to maintain confidence in clinical medicine and patient care. Unless we constantly better our clinical skills we only remain expert technicians and our patients will look for relief elsewhere. We have to set standards of care and conform to them and consistently update them, with a systems approach.