Improving the Quality through

Audits
Dr Arpita Agrawal
Consultant, QI
 What is Audit?

• A systematic review and analysis of any service delivered and its

evaluation in terms of quality within given resources.

• A tool to find out what you do now, in comparison to the past,

what should you do in the future.

• To analyse the best thing in the best way.

 Audits

• Audit is not a Fault-finding exercise, but

a Fact-finding exercise.

• Audits are not for Policing, but for

Polishing.

• Audit is not an External Quality

Assurance method, but an internal
mechanism for Quality Improvement.
 Pre-requisite of an Audit Process

• Good record keeping systems

• Should be carried out by fair and impartial
professionals
• Clinician, nursing and other staff as well as patient
anonymity to be maintained
• Purpose should be simple and clearly stated
• Initiative should come from within & ensure
intention should be to effect change for the better
 Who should be involved?
Depends on size and focus of project…but consider….
• Areas / Professions involved in care
• A&E staff, Bed Manager, Nurse, Porters
• Those required for change to happen
• Senior Healthcare staff, Management…
• Patients / Carers
• Clinical Audit department
• Level of involvement
 Making Audit Easier, Avoid the
Blocks

BEFORE YOU START WHEN YOU START

 Time – big audits can eat up time in an  Delegate & Share the workload –
already busy schedule, so: involve others
 Keep it simple and small  Make life easier – use computers to do
 Look at one or two criteria the laborious stuff (patient searches)
 Engage the whole team – otherwise it  Clear aims must be identified
will be difficult! Is the team ready?  Use protocols / standards already laid
(Enthusiasm, wanting to improve) by others (why re-invent the wheel?)
 Be careful of data collection & choice
of a topic
 Defining the Purpose

Guiding Principles for defining the Example-

purpose of an audit:
- To ensure Partograph is maintained
• to improve the quality for all normal deliveries
• to enhance performance
• to increase efficiency - To increase the average length of
stay after delivery
• to change procedure
• to ensure patient satisfaction - To improve the blood transfusion
• to reduce cost reaction monitoring
• To reduce errors
 Audit Cycle

Preparation
and Planning

Measuring
Sustaining Audit
level of
improvements cycle
performance

Making
improvements
 Stage -1 Preparation and Planning

Constitute an Audit Committee:-

Constitute an Audit
Committee • Like death audit can be conducted by maternal death review committee or
prescription audit by drugs and therapeutic committee
• Committee will be responsible for conduction of requisite trainings
Conduction of
training for Audit Selecting area of interest:-
• Preferably, one which is a high priority for the facility
Selecting Areas of
interest Providing necessary resources:-
• There will be existing guidelines (STGs) defining desired standards for the
area chosen
Providing necessary
Resources Select the criteria:-
• These should be in the form of a statement e.g. Partograph is generated in
at least 90% deliveries in Labour Rooms
• Audit standards will come from standard treatment guidelines or best
Select the criteria practices
 Criteria = yardstick

• “An audit criterion is a specific

statement of what should be
happening.” Appraising
Defining
the
• All delivery oxytocin given at the time evidence
criteria
of delivery
• All patients with asthma should have
their inhaler technique reviewed at
least once a year Sources of
• All patients with MI should get evidence
aspirin within 30 min of hospital
admission
 CRITERIA – KEY POINTS

• Ensure that the criterion is explicit and measurable –

• “All eligible women should have had a cervical smear” (eligibility? which age
group?)
“All eligible women aged 25-65 should have had a cervical smear in the last 5
years”.

• “the overall management of obstetric hemorrhage”

All women with PV bleeding 24 hours or Perceived blood loss of more than
1000 ml. Or patients presenting with clinical signs of shock (pulse >100/min,
<100 mm/Hg systolic blood pressure.)
 Standards

• “An audit standard is a minimum level of acceptable performance for that

criterion.”
• Make sure the standard is directly related to the criterion, also should include a
suitable timeframe
– “At least 80% of eligible women aged 25-65yrs should have had a cervical
smear in the last 5 years.”
– “80% of the times blood transfusion begins within one hour of the decision to
transfuse.”
– “80% patients suspected or diagnosed uterine rupture, emergency surgery
should be performed within 2 hours”
– “100% of drugs in crash cart should be in-date.”
 Standards

How to set standards

• Look at national guidelines (Standard Treatment Guidelines) /
Clinical Protocols
• Literature (journals), textbooks
• Local guidelines
• Discussion with consultants
• Discussion with trainer/partners

KEY POINT: Standards set should be realistic, attainable and applicable

to local circumstances; Justifiable reasons for the standard set
 TYING IT ALL TOGETHER
Examples of Standards & Criteria
Criteria Standards

All children under 2 years should be 90% of registered patients under the
immunised against tetanus and polio age of 2 years should have been
immunised against polio and tetanus

All notes of those patients with an 95% of patients with an allergy to

allergy to penicillin should be marked penicillin should be clearly marked

All patients in the surgery should wait 70% of patients in the surgery should
no longer than 30 minutes before a wait no longer than 30 minutes
consultation before a consultation
 Stage-2 Measuring level of
performance
• Planning data collection

• Methods of data collection

• Handling data

• Analyse the data collected

 Stage-3 Making improvements

• Present the results and discuss them with the

relevant stakeholders in the facility

• The results should be used to develop an action

plan, specifying what needs to be done, how it will
be done, who is going to do it and by when.

• Next step is to implement the action plan to achieve

the desired outcome
 Stage-4 Sustaining improvement

• This stage is critical to the successful outcome of an

audit: it verifies whether the implemented action
plan have had an effect and determines whether
further improvements are needed to achieve the
standards

• Conduct follow-up audit to measure the

improvement made followed by giving back
feedback to the involved stakeholders
 Audits Suggested Under NQAS

• Clinical Audits
• Prescription Audits
• Referral Audits
• Maternal Death Audits
To be done as per
• Newborn Death Audit respective guidelines
• Child Death Audits of MOHFW
 Clinical Audit

• The systematic critical analysis of the quality of clinical care

including the procedures used for diagnosis and treatment, the use of
resources and the resulting outcome and quality of life for the
patients
• Clinical audit is a way of improving the care of patients by using a
multi-disciplinary approach, when appropriate, to look at what you
are doing and see if you can do it better
• Considered as tool not goal
• Clinical audits are done at defined interval by designated team for
randomly selected cases preferably retrospectively.
 Types of Clinical Audits

Clinical Audit
Retrospective
Concurrent Audit
Audit

Care is evaluated at
Care is evaluated after the time it is taking
it has been completed place
through records
Pre-requisites for clinical audit

Clinical audit

Well organized
Medical Audit medical
committee records
Hospital
statistics
 Importance of well organised
Medical Records in Audit

• Clinical record keeping is an integral component in good professional practice

and the delivery of quality healthcare.

• Regardless of the form of the records (i.e. electronic or paper), clinical records
should be updated, where appropriate, by all members of the
multidisciplinary team that are involved in a patient’s care

• Clinical records are also valuable documents to audit the quality of healthcare
services offered and can also be used for investigating serious incidents,
patient complaints and compensation cases
 Gap Identification

• Gap identified after conducting audit could be categorised through

Structure, Process and Outcome

• Structure i.e., facilities being provided /patients complaint too long

to get an appointment

Waiting times
Availability of staff
Record keeping (all patient records should have a summary
card)
Equipment
 Gap Identification

• Process i.e., what was done to the patient - referrals, prescribing,

investigations

High risk pregnancy identified

All women who are estimated to have lost at least 1500 ml of blood
postpartum should receive blood transfusion.
Blood transfusion should begin within one hour of the decision to transfuse.
A fluid balance chart should be maintained during blood transfusion.
Preventative Care - childhood immunization, Cervical Cytology
 Gap Identification

• Outcome i.e., result for the patient

Patient satisfaction
Hypertension patients aged between 20-35 should have a diastolic below
90mmHg within the first year of treatment
High risk practices (significant event audits)
• Pneumococcal vaccines in splenectomised patients, are significant
events being acted upon?
• “Significant events”
• Maternal/neonatal death in low risk pregnancy
• Near-miss case review
• The outcome is the ideal indicator for care but the most difficult to measure.
 Medical Audit

Medical audits are carried out on the case sheets of patients admitted in a facility
over a defined period with the objective of determining the following :

• Whether the admission/treatment was justified

• Whether the diagnosis documented was as per the ICD terminology
• Whether the medicines prescribed were as per the STGs
• Whether the investigations ordered were appropriate
• Whether the follow-up of the patient was timely and appropriate/referred
timely to the appropriate consultant.
• Whether the patient was advised and timely transferred
• Whether the timely detection and treatment of complications was done
 Some ideas for Medical audit

1. Time elapsed between delivery and diagnosis of the haemorrhage

was less than 45 minutes?
2. After diagnosis of the haemorrhage, was manual placenta delivery
or uterine exploration effected in less than 15 minutes?
3. In the case of manual placenta delivery, manual uterine
exploration, or caesarean delivery, were prophylactic antibiotics
administered?
 Some ideas for Medical audit

4. Was oxytocin administered within 15 minutes of observation of

uterine atony?
5. Were prostaglandins administered within 20 minutes of
determining the failure of oxytocin?
6. If haemoglobin fell below 6 g/dl, did colloid replacement take
place or were blood products administered?
7. If no treatment succeeded within 60 minutes of diagnosis of the
haemorrhage or 120 minutes after delivery, was surgical
intervention considered?
 Death Audit

 All deaths occurring after 48 hours of admission should be subjected

to Death Audit.
 All the deaths should be audited every month
 The death case sheets are examined in terms of qualitative and
quantitative adequacy.
 The various parameter used are:
 The diagnosis, investigation, treatment given in comparison to
normal standard.
 Delay in examination, investigation or initial treatment, if any.
 Types of consultations obtained and recorded.
 Daily Monitoring of Progress.
 Prescription Audit

• A prescription audit is a part of the holistic

clinical audit
• It is process that seeks to improve patient care
and outcomes through a systematic review of
care against explicit criteria and the
implementation of change

3
 Common Prescription Errors

1) Prescribing Investigations that are not required

2) Over prescription
a. Straight away 4th generation antibiotics
b. Complex prescription -More than one drugs when only one drug is required.
3) Prescription of tonics without indication
4) Prescribing sugar base tonics to Diabetic patients
5) Advising Investigations outside, when available in Health facility
6) Non-documentation of drugs prescribed other than from Essential Drug List
7) Preference for Branded drugs
8) Unnecessary prescription of Injections
 Objectives Of Conducting PrescriptionAudit

•Detection of prescribing errors with their reasons

•To assess & reduce the irrational usage of antibiotics,
syrups, injections etc
•To identify opportunities for the improvement and
developing benchmarks.
•To channelize the good practice of writing complete,
legible and rational prescriptions
Pre Requisites for PrescriptionAudit

• Correct Prescription Format

Prescription Format • Standardise the prescription format

Essential Medical List • Different Level of facility

• For common conditions & case

STG & Policy for Medicine management
Use • Antibiotic & rational use of drug
Policies to reduce irrational use
Understanding the Audit • Identify why did it happen instead
Philosophy of who went wrong
 ExpectedOutcome

•Improve prescription quality at public health facilities.

•Promote the rational use of drugs
•Reduce the cost of treatment (on Hospital & patient)
by reducing unnecessary prescriptions (e.g.
Antibiotics), efficient use of therapeutic agents,
•Encourage generic medicines, and reducing
polypharmacy.
 TargetAudience

• Primary and Secondary care public health facilities providing Out-Patient

Services,
• District Hospitals (DHs),
• Sub-divisional Hospitals (SDHs),
• Community Health Centres (CHCs),
• Primary Health Centres (PHCs), (Both Urban & Rural)
• Authorised personnel’s prescriptions would be used for the Prescription
audit except medicines given under the National Health Programmes.
• It will be prudent to exclude the prescriptions of medico-legal cases.
• Prescriptions, written for the admitted patients, are examined at time of
conduct of medical audit,
 Audit
M ethodology
 Remember

• Audit is not a Fault-finding

Exercise
Problem or
• But a Fact-finding Exercise objective
identified

• Audits are not For POLICING Criteria agreed

Re- and
• But for POLISHING audit Cyclic standards set

al
• An internal mechanism for Make proce Audit (Data
Quality Improvement necessary
ss
collected &
analysed)
changes
• Audit is not an external Quality Identify areas
for
Assurance method. improvement
Overview of Prescription Audit
Methodology
 Step 1: Formulating an Audit
Committee
• Audit Committee is part or subcommittee of ‘Medicines and Therapeutic Committee’.
• The prescription audit committee should cover the practice of the different clinical and managerial
disciplines
• Committee should know the aim of the audit & their role.

• Suggested members of the Audit Committee:

At DH/SDH and CHC level:
o Hospital In-charge (MS/CMO) (overall Responsibility)
o Hospital Administrator/Manager (wherever available, for conducting and analysing Prescriptions’
findings),
o One Clinician from each department,
o In charge Nursing Services/Matron,
o Chief Pharmacist/Senior most pharmacists managing dispensary and Medical Store.
 Step 1: Formulating an Audit
Committee

• In small healthcare facilities like UPHC and PHCs, Medical Officer,

Pharmacist and one senior nurse may be part of the Audit
Committee.
• Specific details (like antibiotics prescribed, medicines prescribed as per
STGs, no medicines given, etc.) can be audited through peer review by
another Medical Officer of neighbouring health facility.
OR Scanned copies of minimum 30 prescriptions can be sent to District
Quality Assurance Unit (DQAU) for review.
 Step 2: Calculate Sample
Size

• Adequate sample size is essential for Audit

and meaningful evaluation of prescriptions.
• A sample size calculator is provided below
with the Margin of Error (-10%) and
Confidence Level (95%). Facilities having
resources may aspire for calculating sample
size on -5% margin of error.
• The sample (prescriptions selected for audit)
should be representative of the total OPD
attendance.
Sample Size Calculator
given on page 10-11 of the
guidelines
 Step 3: Data Collection

• Simple random sampling techniques may be used.

• Half of the sample should be taken from first two weeks
and half from remaining two weeks.
• Pharmacist/Nurse/Hospital Manger may be assigned
the responsibility of collecting the sample
prescriptions.
• Standardize format can be used for Data collection
(Facilities can follow the format provided Annexure
D (Page 37 &38)of the guidelines
• The states have the flexibility to make any changes
(addition/deletion/modification) in the attributes as
per the state’s policy after approval of the State
Quality Assurance Committee (SQAC)
Sr No Criteria/Attributes
1 OPD Registration Number mentioned?
2 Complete Name of the patient is written?
3 Age in years (≥ 5 in years) in case of < 5 years (in
months)
4 Weight in Kg (only patients of paediatric age group)
5 Date of consultation - day / month / year
6 Gender of the patient:
7 Handwriting is Legible in Capital letter
8 Brief history Written
9 Allergy status mentioned
10 Salient features of Clinical Examination recorded
11 Presumptive / definitive diagnosis written
12 Medicines are prescribed by generic names
13 Medicines prescribed are in line with STG
14 Medicine Schedule / doses clearly written
Sr No Criteria/Attributes
15 Duration of treatment written

16 Date of next visit (review) written

17 In case of referral, the relevant clinical details and reason for

referral given.
18 Follow-up advise and precautions (do’s and don’ts) are recorded

19 Prescription duly signed (legibly)

20 Medicines Prescribed are as per EML/ Formulary

21 Medicines advised are available in the dispensary

22 Vitamins, Tonics or Enzymes prescribed

23 Antibiotics prescribed?

24 Antibiotics are prescribed as per facility’s Antibiotic Policy

25 Investigations advised?

26 Injections prescribed

27 Number of Medicines prescribed.

 Step 4: Data Analysis

• Once the calculated number of prescriptions have been received, all

attributes need to be written in a tabular form.
• Afterward, each prescription is evaluated against these attributes in the
form of observed response as ‘YES’ or ‘NO’.
• The collected information is then transferred into an excel sheet to get a
comprehensive view of prescription practices, indicators’ calculation,
gap identification, and best practices.
• The compliance & noncompliance need to convert into Percentage
• Two lowest-performing attributes have been identified to prepare an
action plan with a defined timeline.
Data Analysis &Calculation
Data Analysis &Calculation
 Step 5: Take Action & Make Improvement

1. Low performing attributes need to

identify Find the
Problem
2. Do the root cause Analysis –using
Brainstorming &Why –why analysis Prevent Find
etc. Future
Problem
QI For the
Root
Prescripti
3. Develop the time bound action plan on Audit
Cause

4. Share the finding & action plan with

all physicians of the Hospitals Correct
Take
necessa
the r y
5. Improve the lowest performing problem action
to make
attributes using PDCA Cycles changes

6. Sustain the Improvement

 Step 6: Follow upAudit

• A follow-up audit should be

performed on a regular basis
• To ensure that the improvement cycle is
completed and identified gaps have been
closed.
• To analysis the trends over a period
Thank
you