Medical audit systems are crucial to improving the quality of patient care and making efficiency gains in health care systems. But many countries struggle with the complexities of establishing or strengthening their medical audit schemes.
The Joint Learning Network for Universal Health Coverage (JLN), in collaboration with South Korea’s Health Insurance Review and Assessment Service (HIRA), has been working with eight countries, including Colombia, Ghana, India, Indonesia, Kenya, Malaysia, Nigeria and the Philippines, to share expertise and best practices in designing medical audit systems. The group of practitioners and policymakers has just launched a comprehensive guide for fellow practitioners, the Toolkit for Medical Audit Systems: Practical Advice from Implementers to Implementers.
Defined as a quality improvement process with a step-by-step analysis of health care services against explicit criteria relating to quality and cost, well-designed medical audit systems can ensure effective and financially sustainable health care systems and improve patient outcomes.
When the delivered care or health outcomes fail to meet established benchmarks in a medical audit, practitioners have vital data on the changes that should be implemented at an individual, team or service level.
The Formation of the Medical Audits Collaborative
The participating JLN member countries formed a collaborative working group to address what practitioners had identified as common challenges in designing and implementing medical audits within their national health insurance programs.
Participants included technical professionals focusing on claims, quality assurance and monitoring and evaluation in national health insurance agencies; medical practitioners, professors and researchers; and policymakers from national ministries of health.
South Korea, a new member of the JLN, hosted three in-person meetings to support fellow member countries in thinking about how to design and implement medical audits to improve quality of care. South Korea has one of the most well-established and highly-functioning medical audit systems today, leading the collaborative to identify HIRA as a reference point for best practices in medical audit systems.
Throughout the in-person and virtual meetings, the collaborative discussed common challenges and exchanged experiences, defined the components of a medical audits framework within a health insurance program, and identified tangible recommendations for strengthening medical audit systems within the context of their countries.
Equipped with this collective knowledge, the participants worked collaboratively to produce a practical toolkit for their fellow practitioners on how to design, implement and strengthen medical audit systems.
The Medical Audit Systems Toolkit and Framework
Developed from the perspective of purchasers of care, such as national health insurance agencies, the Toolkit provides comprehensive recommendations for designing and implementing medical audit systems and includes best practices, country examples, and solutions to common challenges.
Results from a medical audit can guide actions and recommend changes to the individual, team, service or system levels. Practitioners can then further monitor the changes to identify improvements in the quality and efficiency of the health care system.
The Toolkit also walks the user through a medical audits framework. Essential components of a medical audit framework include:
- Inputs: preconditions for enabling a successful medical audit system
- Processes: the development of indicators, rules, and triggers to ensure effective medical audits and the process of conducting the audit, including onsite and offsite investigations
- Outcomes: the overarching goals of improved quality, patient outcomes and financial elements of risk protection and sustainability
The figure below illustrates the medical audit system framework adopted by the collaborative, featuring the perspectives of policymakers, purchasers of care (such as insurers), health care providers and patients.
The collaborative also developed cross-linkages with JLN Data Analytics collaborative, which focuses on collecting indicators for provider payment mechanisms, complementing the work of the Medical Audits collaborative around the process of developing audit triggers. For example, one step in the Medical Audits toolkit requires the development of indicators for claims reviews, drawing directly from the co-produced knowledge in the Using Data Analytics to Monitor Provider Payment Systems manual.
As the technical coordinator of the collaborative, ACCESS Health International synthesized and developed the content for the toolkit based on case studies, country examples and critical insights shared by participants. The toolkit will be officially launched at an event in South Korea, hosted by HIRA, in December 2017.
Applying the Toolkit in Nigeria and the Philippines
The discussion during the in-person and online meetings have already supported member countries to take immediate steps to strengthen their respective medical audit systems. Participation in the collaborative helped the Philippines’ national health insurance agency, PhilHealth, to train its staff on data quality and the importance of data standardization. PhilHealth is currently working with a consulting firm to determine thresholds for fraud identification triggers. Meanwhile, Nigeria’s national health insurance agency launched a capacity-building program for staff working in the medical audits program.
Next Steps for Quality Health Systems
Following the launch, the JLN will work with member countries to adapt, apply and implement the toolkit. The Medical Audits collaborative plans to continue engagement through a community of practice, identify in-country champions for designing efficient medical audit systems and explore in-country dissemination opportunities. JLN member countries can also take advantage of the Joint Learning Fund to start initial learning and application of best practices in their countries. As countries increasingly have the opportunities, knowledge, and resources to improve their medical audit systems, they will move ever closer to their common goal of ensuring universal access to high-quality health care.
Medical Audits Improve Quality of Care and Lower Costs in South Korea
Medical Audits Collaborative: Phase III Meeting in Seoul and Wonju, South Korea
Applying Learnings Back Home: Medical Audits Collaborative
Impact of Medical Audits Learnings on Nigeria’s Health System
Improving Health Care Through Medical Audits
A New Toolkit for Medical Audit Practitioners: Ensuring Quality Across Health Systems