Improving Healthcare Through Medical Audits

ACCESS Health is one of the founders of the Joint Learning Network, an innovative knowledge network for low and middle income countries who are focused on expanding health coverage for all citizens.

A group of network members recently formed a Medical Audits Collaborative, with ACCESS Health acting as coordinator. In early September, the Collaborativemet in Wonju, South Korea to further improve the quality of healthcare through the development of a medical audit system. A medical audit system is a process by which patient care and outcomes are reviewed and evaluated against explicit criteria. When the care delivered and the outcomes don’t meet the benchmarks in the audit, changes are implemented at an individual, team, or service level.

Sixteen representatives from seven Joint Learning Network member countries (Ghana, India, Indonesia, Kenya, Malaysia, Nigeria, Philippines) met August 29 to September 2 to share new developments since the Phase I meeting of the Medical Audits Collaborative, held earlier this year.

Members of the Collaborative are technical practitioners involved in the design and management of medical audit systems in their countries. In the months leading up to the second meeting, participants led small virtual technical group discussions to dive deeper into the structural and procedural components of a robust medical audit system. They discussed elements such as: the definition of medical audits, governance and administration, human resource and capacity building. indicators, rules and triggers, functional requirements, site investigations, and clinical audits.

All member countries were enthusiastic and forthright in sharing country case studies, anonymized information and data with each other. Members were hopeful that the Collaborative would help make country case studies more available and help in developing a set of simple, practical and adaptable steps to develop a strong medical audit system.

Members received sustained input and guidance from Health Insurance Review and Assessment Service (HIRA), the independent claims review and quality assessment institution under the aegis of Ministry of Health and Welfare in South Korea. HIRA presentations enriched discussions with examples and frameworks from South Korea’s advanced medical audit system.

Some of the progress made during the meeting includes:

Members agreed on a definition of Medical Audits for use by the Collaborative:

A medical audit system is “a quality improvement process with a comprehensive and step-by-step analysis against explicit criteria of quality of care and cost that seeks to improve patient outcomes and financial risk protection for an effective and efficient healthcare system.” Where indicated changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvements in healthcare delivery.

Members agreed on the need for a clear, standard methodology for medical audit that can hold up under scrutiny

There is a need to set linkages to strong IT systems for data quality

It is important to establish and maintain engagement with all stakeholders

The group discussed the functional components of a strong medical audit system: an administrative and regulatory structure, budget provisions, personnel needs, and advocacy support

The group made advances in selection of indicators to conduct medical audits; based on common themes observed out of country examples, it will be important to take into account the perspective of insurer, policymakers, providers, and members to define indicators

For site investigations, the group looked into triggers, legal processes, human resource and tool requirements; members also talked about the value of “thinking like a fraud” to undertake site investigations.

Quality improvement, financial sustainability, financial risk protection, fraud detection, equity, efficiency, and effectiveness were viewed as primary goals of the medical audit process

Lack of human resources and financial resources, robust data, incomplete records,, and security concerns were some of the shared challenges faced by member countries

In a closing message, HIRA noted that the Collaborative was a “mastermind group” to develop an ideal medical audit system; additionally, HIRA highlighted the importance of data as the lifeblood of a National Health Insurance System, the need to complement ICT with capable human resources, and the significance of building a legacy of success by creating strong audit systems that could withstand national and international scrutiny

Between now and the Phase III meeting of the Medical Audits Collaborative, the group will continue to engage through regular virtual engagements to:

Fine tune content within each subgroup

Integrate country case studies and best practices into the toolkit

Agree upon future use of the toolkit

Develop a mechanism to integrate medical audits within larger systems and ensure corrective action based on audit findings

The Collaborative will leverage work by other Joint Learning Network collaboratives in these efforts, beginning with the Quality Collaborative.