The Importance Of Quality Assurance In Medical Setting

Abstract

The present time demands perfection in all aspects of world and healthcare is not far behind. With the increase in awareness of patients’ rights and healthcare provider’s duties, the demand for quality assurance in health care has become immense. Evidences have shown that one of the effective means to assure quality in care to patients, medical or clinical audit can play a substantial role. Ministry of Health and Population, Government of Nepal has included medical audit as an important component of Quality assurance Working Committee at district level. The medical audits provide a method of feedback and enhance professional development effectively thus enhancing patient outcomes. Godeny (2012) stated that medical audits is a pillar of clinical governance and an integral part of quality assurance. If conducted on a regular basis without any constraints and with adequate resources it can bring major changes in healthcare quality.

Introduction

The onset of 21st century has seen a definite shift in demands of quality health care, pressurizing the governments to look into health sectors from the client’s perspectives. In order to ensure that quality in healthcare is given the highest priority many organizational changes, reviews in policies and funding have been made worldwide.

According to Degenberg (1994), the concept of quality assurance had gained momentum since late 90s. But Brenda et al (2014) noted that history of quality in healthcare however began with Florence Nightingale in 1854 England emphasized on Quality Improvement Documentation, Sanitary Commissions by Barton, USA, sterilization, pharmaceuticals, so on and so forth.

The Institute of Medicine (IOM, 2000), Washington has defined quality in healthcare as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.

The operational definition of Quality assurance as mentioned in Policy on Quality Assurance in Health Care Services 2064 by MOHP, Government of Nepal is, Quality Assurance is a continuous process which includes series of activities for improving and maintaining optimum level of quality of health care services that includes mainly; setting standards and protocols, communicating standards, developing indicators, monitoring compliance with standard and solving problems by team approach.

Merry (2013) mentioned that the essential purposes of Quality Assurance are to improve, quality, safety and experience of care for individual patients, followed by health and equity and greatest value for existing resources. The government’s commitment to in establishing Quality assurance in all sectors and ensure quality of services has been recognized in second long term health plan (SLTHP), medium term strategic plan (MTSP) and Nepal Health Sector Programme-Implementation Plan (NHSP-IP) 2004-2009.

One of the scope of work of QA Working Committee at district level (MoHP, Nepal, 2064) acknowledged is to conduct medical audit at district hospitals, private nursing home and NGO hospitals in the district and give feedback for quality improvement and is used as indicator for measuring process in Quality of care indicators. The Regional Strategy on Patient Safety (SEARO, WHO, 2014), has mentioned Nepal’s initiatives to include quality assurance system till PHC levels with one of the element being establishment of medical audit system.

One of the functions of quality assurance is to monitor quality of care in all health care facilities ensure safety and minimize risk, audit becomes an indispensable segment. The role of Government of Nepal in ensuring continuous supervision, monitoring and evaluation of quality assurance programmes by utilizing appropriate indicators seems paramount. Audit is a fundamental element of improvements to quality of patient care. ISO (2015) described that medical or clinical audit, often substitutable, is an integral component of quality assurance thereby ensuring quality improvement. Three types of audits are done in hospitals: external audit, internal audit and clinical audit. Clinical audits differ from other two types as it is initiated and done by healthcare professionals often taking place continuously.

The definition of Clinical audit as per Quality Assurance Best Practices (2002) is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery.

Hut-Mossel et al (2017) claimed that clinical audit is a corroborated tool at all healthcare levels, working in six step cycle which includes identification of problem, defining and setting standards, collecting data, analysing data, implementation of change and re-audit. Pertti (1983) observed the elementary standard of medical audit was to compare the care provided to patients with specified standards.

Findings

Soliman (2018) specified that clinical audit is an asset which invested wisely will payback in greater quality of services provided by the healthcare institution. Piryani et al (2018) detailed that several types of audit are conducted in hospitals whereby clinical audit has demonstrated to be most well-regarded, sustainable and essential instrument in ensuring quality care by measuring clinical outcome. Robert (2014) indicated that clinical audit is one of the easiest ways to refining quality in hospital and should be encouraged by all heath care practitioners.

The Institute of Internal Auditors (IIA, 2013) stated in its 2013 position paper that clinical audit is the third line of defence after management and risk control for any size of healthcare organization. National Institute for Health and Care Excellence (NICE 2002) cited that clinical audit was integrated in clinical governance and full participation by all doctors and healthcare staff was made mandatory in the NHS Plan. It increased professional accountability as it becomes an important tool in retaining trust and respect in today’s critical environment of high demand and pressure, press coverage, legal claims and complaints.

A clinical audit conducted for ICU at Zonal hospital in Nepal, Paneru et al (2017) stated that it had helped them identify issues and problems regarding quality of care and thereby providing help to plan out quality improvement programmes. They also stressed on the need to establish a separate audit unit. A clinical audit of all obstetrics referrals done at BJRM (secondary level facility) from 1st May to 31st October 2016,Dubey et al (2017) presented that standard referral protocol and well-defined linkages needed to be established so as to have better coordination between the referral units and tertiary centres.

In a hospital based prospective, descriptive study, clinical audit was conducted by Gurung et al (2015) which showed maternal near-miss event was due to obstetric haemorrhage followed by hypertension and sepsis and nearly all the cases were well managed in ICU. A descriptive cross-sectional study was designed and all patients admitted to the intensive care unit of TUTH, clinical audit by Acharya et al (2018) presented the profile of patients admitted in a super specialised hospital in Nepal along with their indications and mortality levels. The most frequent patients being admitted were of Neurosurgical ward and the mortality was considerably higher compared to ICUs in developed countries.

In a retrospective descriptive study by Sajid et al (2010), a clinical audit was steered to determine the status of coagulation disorders in a haemophilia care centre in Pakistan which showed a need for state involvement to improve the availability of up-to-date haemophilia care services. A study by Areti (2009) was conducted targeting to examine the relation of Clinical audit with quality of care and showed that it is a influential educational tool to assure and assess quality of patient health care generating prospects to learn and to enhance experience.

A comparative analytical study by Fiuseppe et al (2014) detailed that clinical audit leads to improved patient outcomes by cultivating good clinical practice and empowers health care practitioners to enhance their professional growth from peer review and feedbacks. It is noted that in the research that case study analysis helps to discuss alternative options for patient care. Mindfulness of surgeon’s performance and preparation may improve services to people. It is a keystone for clinical governance as it requires continuous professional development. On the other hand it offers chance for continuous organisational improvement by monitoring in detail all the routine work of clinical practice. It leads to strengthening of health system by ensuring that maximum efforts are being taken to ensure best patient care. It ensures adherence to standard procedures and protocols at all times.

Esposito et al (2014) proved clinical audit to be a popular and widespread tool for monitoring level of health care quality and effectiveness in nephrology and advocates its promotion at both national and international level. A comprehensive literature review by Johnston et al (2000) of 93 publications showed that perceived benefits of clinical audit includes professional benefits, improvements in patient care and the quality of service. An opinion survey conducted by Bhaskar et al (2012) in Nizam’s Institute of Medical sciences found doctors interested in implementation of Medical audit by a representative committee with very few criticizing the system.

The results of two clinical audits conducted by Hirvoene-Kari et al (2009) in southwest hospital district of Finland regarding radiation use showed positive impact on work procedures in radiological department. Dixon (2011) identified that although clinical audit has become a significant activity in numerous healthcare organisations in England, some evidence suggest that its ineffectiveness maybe due to professionals seeing it as quality assurance and not quality improvement process. A study by Ivers et al (2012) showed that in a systematic review of 140 studies of clinical audit and feedback conducted by Cochrane study group noted that small to moderate effectiveness of clinical audits.

A Dutch study by Grol and Wensing (1995) of 120 general practitioners found that, in addition to financial support, the main requirements for implementing quality assurance programmes and medical audit were regular meetings with colleagues, information on the aims and methods of quality assurance, support in setting up audit and in data collection, and peer review. Johnston et al (2000) identified clarity of design, appropriate data collection method, decent planning, support of institution, dedicated and devoted staff and collective analysis of results as facilitators of clinical audit. Routine data collection, access to information technology and support of colleagues are deemed necessary for a successful medical audit. On the other hand, resource scarcity, increased workload, ambiguous methodology, lack of organizational support, reluctance to transform are the observed obstacles.

Since no tool is without limitation, medical audits needs to be adapted and revised for different setting. In context of Nepal, very few literature are available possibly due unpublished audits even though they are being conducted at least hospitals. Nepal being a developing country is more likely to face afore mentioned barriers in successful and regular implementation of medical audits. The major limitations in steering a medical audit as stated by Kogan and Redfern (1995) are unavailability of desired time, lack of funding, lack of technical expertise and trained support staff. Sometimes in rural areas, inaccessible information technology may seem as a constraint. A multi-professional audit may seem as an obstacle to autonomy, unfair appraisal method, means of dictatorship by seniors thereby unable to achieve equity and respect. Robinson (1996) specified relations between clinical audit team members and organisation impediments are added barriers.

Conclusion

From the above findings it is evident that medical audit is a powerful tool as a component of quality assurance. Efficiently and rigorously implementing medical audit will improve hospitals performance and ensure quality assurance at service delivery levels. In order to provide sustainable healthcare quality clinical audit process is a strong endorsement.

The concept of healthcare governance is yet to be formally introduced by all concerned health care authorities making suitable changes in governance strategies and policies. Kaini (2013) identified that structure has to be appropriately understood to promote openness, realise accountability and support healthcare governance. Following the above observations and barriers, some measures are recommended for medical audit to be successfully brought into effect in Nepal to ensure quality assurance at all levels of healthcare.

Clinical audit should be at the core of system at monitoring performance. It should be fully supported by the healthcare organization and its staff. It should be conducted effectively with time, facilities and expertise provided. Standard protocols should be reviewed and revised periodically to maintain standards. It should be compulsory for all health professionals and should be made a part of contract of employment. It should also be a part of clinical rotation for junior doctors. It helps locate performance gaps and offer understanding of workable answers to quality assurance. It should be accentuated by all health related professional bodies, regulators and government of Nepal. Service users should also be actively participating. Organizations should ensure adequate skills and trainings of clinical audit. Organizers of audit programme different ways and means to ensure full and active participation of all healthcare staff. Medical records should be ensured for completeness and submission to higher authorities. Unbiased, experienced doctors and health care professionals representing all departments to form the core audit team. Annual audit should be conducted by external authority to ensure excellent quality standards.

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