Medical Audits Collaborative Phase II Meeting in Wonju, South Korea Sep 28, 2016

Medical Audits Collaborative Phase II Meeting in Wonju, South Korea

“Medical Audits Collaborative aims to strengthen, establish, improve medical audit systems in member countries with a larger aim to bring improvement in monitoring quality of care”

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. Effective medical audit systems help countries improve their quality of health care. 
In the spirit of collaborative learning, and building on the momentum of the first in-person meeting, sixteen representatives from seven Joint Learning Network member countries (Ghana, India, Indonesia, Kenya, Malaysia, Nigeria, Philippines) met in Wonju, South Korea from August 29 - September 2 to kick of the second in-person meeting of the Medical Audits Collaborative.
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.  Below are a few discussion highlights:
  • Members agreed on a definition of Medical Audits for use by the Collaborative which includes dimensions of quality and cost.   
  • 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.

Lessons from South Korea

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. In many ways, the South Korean example proved to be highly inspiring, serving as a strong reminder that effective medical audit systems can make a profound impact on a country’s quality of healthcare.
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.

What’s next?

The second in-person meeting of the Medical Audits Collaborative enabled members to dive deeper into technical topics associated with medical audit. Going forward, the group will continue to exchange on practical steps towards developing strong medical audit systems, which they will disseminate in a practical to be finalized early 2017.
Specifically, members will re-convene in Dec 2016 to deep dive into the following topic areas:
  • 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.