Reliability of medical audit in quality assessment of medical care

Medical audit of hospital records has been a major component of quality of care assessment, although physician judgment is known to have low reliability. We estimated interrater agreement of quality assessment in a sample of patients with cardiac conditions admitted to an American teaching hospital. Physician-reviewers used structured review methods designed to improve quality assessment based on judgment. Chance-corrected agreement for the items considered more relevant to process and outcome of care ranged from low to moderate (0.2 to 0.6), depending on the review item and the principal diagnoses and procedures the patients underwent. Results from several studies seem to converge on this point. Comparisons among different settings should be made with caution, given the sensitivity of agreement measurements to prevalence rates. Reliability of review methods in their current stage could be improved by combining the assessment of two or more reviewers, and by emphasizing outcome-oriented events.     

新型农村合作医疗绩效审计指标体系研究

目的:为新型农村合作医疗提出一套合理、可行的绩效审计指标体系。方法:使用修正的平衡计分卡,对其进行评价,结果:从五个维度,用37个指标对新农合进行系统全面的评价。结论:该指标体系符合当前的实际情况,通过调查问卷以及审计取证获取该体系所需要的数据,较好的评价了新农合的绩效。     

The role of clinical audit in the quality improvement of health care

The aim of clinical audit is continuous improvement of the quality of care through systematic and critical review of current practice against explicit criteria and the implementation of change if necessary. The audit is a regular multidisciplinary activity by which all participants of care including doctors, nurses and other health professionals carry out a systematic review of their own practice. Data collected during the process of audit should be handled with care, and individual data concerning care-givers, patients or health professionals must be treated confidentially. Clinical audit needs realistic timeframe and necessary resources as well as tolerant culture of learning organisations. Furthermore the success of clinical audit depends on the commitment and support of the management of the organisations. Clinical audit could relatively easily be embodied into the current practice of peer-review processes and other quality improvement initiatives in Hungary. Widespread and systemic application of clinical audit may improve the quality of patient care and maintain the trust of the population. However, clinical audit should be effective and cost-effective. The recently published methodological guideline by the Ministry intends to promote good practice in clinical audit.     

Promoting audit in primary care: roles and relationships of medical audit advisory groups and their managers.

OBJECTIVES--To investigate perceptions of family health service authorities and medical audit advisory groups of advisory groups' involvement in clinical audit and wider quality issues; communication with the authorities; and manager satisfaction. DESIGN--National postal questionnaire survey in 1994. SETTING--All family health services authority districts in England and Wales. SUBJECTS--Chief executives or other responsible authority officers and advisory group chairpersons in each district. MAIN MEASURES--Priorities of advisory group and authority for audit; involvement of advisory group in wider quality issues; communication of information to, and contacts with, the authority and its involvement in planning the future work of the advisory group; and authorities' satisfaction. RESULTS--Both groups' views about audit were similar and broadly consistent with current policy. Advisory group involvement in wider quality issues was extensive, and the majority of both groups thought this appropriate. Much of the information about their activities collected by advisory groups was not passed on to the authority. The most frequent contact between the two groups was the advisory group's annual report, but formal personal contact was the most valued. Most authority respondents thought their views had been recognised in the advisory group's planning of future work; only a small minority were not satisfied with their advisory groups. Dissatisfied respondents received less information from their advisory groups, had less contact with them, and thought they had less input into their plans. There was some evidence that advisory groups in the "dissatisfied districts" were less involved in clinical audit and with their authorities in wider quality issues. CONCLUSIONS--Most advisory groups are developing their activities in clinical audit and have expanded their scope of work. The quality and availability of information about progress with audit is a cause for concern to both groups.     

Quality assurance and quality improvement in medical practice. Part 3: Clinical audit in medical practice

The first two articles in the series were about the definition of quality in healthcare, the quality approach, the importance of quality assurance, the advantages of quality management systems and the basic concepts and necessity of evidence based medicine. In the third article the importance and basic steps of clinical audit are summarised. Clinical audit is an integral part of quality assurance and quality improvement in healthcare, that is the responsibility of any practitioner involved in medical practice. Clinical audit principally measures the clinical practice against clinical guidelines, protocols and other professional standards, and sometimes induces changes to ensure that all patients receive care according to principles of the best practice. The clinical audit can be defined also as a quality improvement process that seeks to identify areas for service improvement, develop and carry out plans and actions to improve medical activity and then by re-audit to ensure that these changes have an effect. Therefore, its aims are both to stimulate quality improvement interventions and to assess their impact in order to develop clinical effectiveness. At the end of the article key points of quality assurance and improvement in medical practice are summarised.     

Audit activity and quality of completed audit projects in primary care in Staffordshire.

OBJECTIVES--To survey audit activity in primary care and determine which practice factors are associated with completed audit; to survey the quality of completed audit projects. DESIGN--From April 1992 to June 1993 a team from the medical audit advisory group visited all general practices; a research assistant visited each practice to study the best audit project. Data were collected in structured interviews. SETTING--Staffordshire, United Kingdom. SUBJECTS--All 189 general practices. MAIN MEASURES--Audit activity using Oxford classification system. Quality of best audit project by assessing choice of topic; participation of practice staff; setting of standards; methods of data collection and presentation of results; whether a plan to make changes resulted from the audit; and whether changes led to the set standards being achieved. RESULTS--Audit information was available from 169 practices (89%). 44(26%) practices had carried out at least one full audit; 40(24%) had not started audit. Mean scores with the Oxford classification system were significantly higher with the presence of a practice manager (2.7(95% confidence interval 2.4 to 2.9) v 1.2(0.7 to 1.8), p < 0.0001) and with computerisation (2.8(2.5 to 3.1) v 1.4 (0.9 to 2.0), p < 0.0001), organised notes (2.6(2.1 to 3.0) v 1.7(7.2 to 2.2), p = 0.03), being a training practice (3.5(3.2 to 3.8) v 2.1(1.8 to 2.4), p < 0.0001), and being a partnership (2.8(2.6 to 3.0) v 1.5(1.1 to 2.0), p < 0.0001). Standards had been set in 62 of the 71 projects reviewed. Data were collected prospectively in 36 projects and retrospectively in 35. 16 projects entailed taking samples from a study population and 55 from the whole population. 50 projects had a written summary. Performance was less than the standards set or expected in 56 projects. 62 practices made changes as a result of the audit. 35 of the 53 that had reviewed the changes found that the original standards had been reached. CONCLUSIONS--Evaluation of audit in primary care should include evaluation of the methods used, whether deficiencies were identified, and whether changes were implemented to resolve any problems found.