Dr. Anwar Marthya
Senior Lecturer in Orthopaedics
Medical College Calicut
Addresses for Correspondence
Dr. Anwar Marthya
Senior Lecturer in Orthopaedics
Medical College Calicut
Medical audit is currently the
subject of much talk as demonstrated by its high profile
throughout the medical literature. The Royal College of
Physicians of London now seeks evidence of sound medical audit
as a condition for the recognition of higher training. It is
also important for allocation of funds given by health
authorities. Despite all the words that have been written and
spoken about audit, it is not a new concept. The word audit is
of Latin derivation and means ‘hearing’. It dates back to
biblical times when it was customary for a landowner to ask his
steward to give an account of the way in which his property was
being put to use. One of the earliest examples of medical audit
goes back to 1912 when the American College of Surgeons required
applicants for fellowships to submit 50 records for
inspection. The poor response to this request led to a proper
procedure for keeping records being devised.
With an expansion in the variety
of health care services, there is now a need to look more
critically at the effectiveness of these services. Audit is now
generally seen to be a necessary requirement for quality health
care. It is now seen as the norm rather than the exception.
Audit is fast becoming a fact of professional life. Outside
pressure have also been instrumental in creating the present
environment for audit. The relationship between the medical
profession and the general public has changed over recent
years. Actions now have to be justified and the professions
are now more aware of the need for maintaining high standards of
Despite so much having been written about audit,
people still differ in their understanding of what it is.
Audit is about taking note of what we do, learning from it and
changing if necessary. Medical audit is the improvement in the
quality of care through standard setting, peer review,
implementation of change and re-evaluation. Audit is about
looking at what you are doing with a view to arriving at
acceptable guidelines and evaluating the outcome. Although
there is no perfect definition of audit, there is general
agreement about its key components.
Components of an Audit:
Expectation: These can be your colleagues’ expectations or
your patients’ expectations. These expectations regarding
performance, whether individual or collective, have to be
The next stage requires the desire and ability to enquire in a
skilful and objective fashion into specific areas of your
Evaluation: Without proper evaluation, the issue of
enquiry is meaningless. This stage involves the critical
analysis of the information resulting from the enquiry which
may result in the decision to implement change.
Education: This stage results from the experiences gained
during the three previous stages. You are educating yourself
to continue to enhance care.
Enhancement: The aim
of the entire process is the enhancement of care and a fuller
understanding for the patient and providers of what is going
on. Enhancement includes efficiency, effectiveness and
What can Audit Measure?
three main constituents of care which can be measured by audit
are frequently referred to as 1)structure, 2)process and
Structure is the resources and personnel available to
you. The quantity and types of resources which are available
to you are 1) the number of staff 2) the use of specialized
equipment 3) the availability of beds.
is what happens in your practice/hospital unit? It is about
the delivery of care to a select group of patients.
1)referrals to hospital 2) clinical investigations
3)procedures done 4)the quality of clinical notes
is the results of your care. It measures the effectiveness of
the care given to a particular group of patients. The audit
can assess how many patients had returned to work three months
after Posterior Lumbar Interbody fusion for segmental
instability of spine.
The type of audit used will
depend on the aim of your audit and what you are trying to
Audit Vs Research:
Is audit the same as
research? The boundaries between audit and research are not
clear-cut. Indeed audit and research have much in common.
They both share a rigorous approach to methodology. Whether
you are involved with research or audit it is important to
recognize and adhere to the strict disciplines within each.
Audit aims to review current practice by using existing
knowledge and to improve patient care in the practice/hospital
setting. It is based on current information about standards of
Criteria Vs Standard:
Two important words in audit are Criteria and Standard. Audit
criteria are general statements about the delivery of patient
care. They focus on those aspects that can be used to assess
the quality of such care. From criteria you can develop
standards applicable to your own practice or hospital unit.
The standard is the proportion of time you feel that the
criteria can be fulfilled to ensure quality of care. Examples
Children under 2 years should be
immunized against polio
90% of 2 years olds are immunized
Penicillin sensitivity must be marked
in red color on the clinical notes
100% of patients sensitive to
penicillin are marked on red color on clinical notes
Reduction of infection after THR
Infection reduced to less than 5% after
What is the desired level of Performance?
Implement possible change
What actually happens
in the hospital unit
There are different methods
of arriving at suitable standards. Those involved in audit have
to decide on the level of care which they consider desirable.
The standard can be derived as follows,
consulting the relevant literature and
based on evidence from your own
experimental work and observations
you can actively develop your own
A combination of the three
above seems to be the best solution for most audits. It is also
be beneficial to examine closely the practice or unit
performance before agreeing on standards. The educational
aspects of audit are highlighted by this method as it can lead
to useful exchanges of ideas, information and opinions within
the group. There will be times when the level of standard will
be easy to decide upon, i.e. 100%; as in case of 100% of
patients sensitive to penicillin are marked on red color on
clinical notes. In many cases this maximum standard may be very
difficult to obtain. Ensure that your standards are realistic
and practical. A minimal standard is simply the minimal
acceptable level for the proper care of the patient to be
maintained. With the highest realistic standard, you are trying
to achieve the best possible standard of care.
There are no
simple answers about the numbers and type of personnel that
should participate in audit. The emphasis is on the health care
team with the key aim of enhancing patient care. The level of
teamwork and the way in which groups function together are of
considerable importance in setting up audit projects.
are an integral part of a number of audit exercises. It is
important that they are informed of what is happening and
encouraged to give their feedback. Doctors will make up the
majority of audit participants. Ward sisters, hospital
pharmacists, medical secretaries and community nurses are some
examples of likely participants. For audit to succeed, definite
commitment is needed by senior doctor staff. Many specialties
require interdisciplinary collaboration and a fundamental
principle of audit should be to encourage the development of
multidisciplinary audit procedures. Involving health care
professionals other than doctors in audit is considered valuable
to audit process and to the improvements of education and
While it is
feasible for individuals to carry out audit on their own it is
more beneficial to work within a group. Ideas and methods can
be shared about an audit project and this can remove the feeling
of isolation that can occur in daily practice. Bringing people
together to look constructively at aspects of clinical care can
enhance the delivery of care to patients.
Once the participants of the
audit team are successfully identified, you should identify the
various responsibilities of each member. The group should
consider carefully the specific jobs that demand attention.
Try to ensure that each person feels comfortable in their
role. The tasks of keeping the minutes of the meetings, task
of keeping the group informed about what is happening, the task
of data collection, the task of analysis etc should be entrusted
to the participants and should be executed meticulously. The
importance of communication in the audit process cannot be
overestimated. It is essential to have good communication
within the group to maintain sensitivity and cohesion. This
encourages an atmosphere to develop where ideas and opinions are
aired freely. Regular feedback about progress is an essential
component of any audit project.
For Successful Audit:
To get commitment to the audit each person
should feel involved and have a sense of ownership. They
should also feel confident that they have the support of an
audit group. Involvement in audit should be encouraged from the
start. At the initial meeting each participants should be made
to feel that they have an important role to play. Clarify their
roles early in the proceedings. Support for individuals within
the group should be available at all times. If group support is
perceived then it will encourage greater enthusiasm and create a
positive attitude towards the exercise.
References And Reading:
1)Shaw CD and Costain DW. Guidelines for
medical audit. BMJ, 1989, 229:498-499.
2) Medical Audit. Working Paper 6. London, HMSO, 1989.
3) Hopkins A. Measuring the Quality of Medical Care. Royal
College of Physicians, London, 1990
4) Baker R. The future of general practice. Audit and standards
in new general practice. BMJ 1991, 303:32-34.
5) The Royal College of Physicians. Medical
Audit: A First Report. London, Royal College of Physicians,