A medical audit system 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. Effective medical audit systems help countries improve their quality of health care.
With collaborative learning on everybody’s mind, representatives from Colombia, Ghana, India, Indonesia, Kenya, Malaysia, Nigeria, and the Philippines met in Wonju, South Korea from March 29-April1 to kick-off the first in-person meeting of the Medical Audits Collaborative to share unique experiences, challenges, and ambitions related to designing, managing, and improving medical audit systems in their respective countries. South Korea, a new member of the JLN, hosted this first meeting to help other member countries begin to think about how to use medical audits to improve quality of care and lower costs. Below are a few discussion highlights:
- There are two dimensions to medical audits: quality and cost. Many members expressed the need to use audits as a means of quality assessment and improvement and to ensure value for money.
- There needs to be a distinction between clinical audits and medical audits.
- Participants asked the following question: How does one create a Culture of Quality to increase the acceptance of audits and relationships with providers?
- Many countries today share the challenge of not yet having developed robust Quality/Data Measurement Systems and are still thinking through how to measure and use the data that they have.
- Human Resources and Capacity continues to be a challenge: how can countries work with people in the smartest way possible given budget constraints?
- Information Technology is key to an effective medical audit system in the long term. It includes various items like storage and analytics, bandwidth, and how to develop a functional system.
- Standardization is also crucial. This includes clinical standards, and standardizing audit processes.
A medical audit system 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." Source: NICE UK, Principles of Best Practice in Clinical Audit 2002] How can effective medical audits systems help countries improve their quality of health care?
South Korea – A pillar of success
What made the workshop especially exciting was that participants had a chance to gain first hand exposure to South Korea’s advanced medical audit system. For example, Young Ae Jung, the Collaborative’s technical facilitator, at the Health Insurance Review and Assessment Service (HIRA) introduced participants to the Korean National Health Insurance System and HIRA’s work, and provided an overview of the four main technical topics related to medical audit systems: (1) Claims Review; (2) On Site Investigation; (3) Quality Assessment; and (4) Drug Utilization Review (DUR).
Members visited HIRA’s Information and Communication Technology Centre and a tertiary hospital to see all the components of the Korean system in action, and also received demonstrations of HIRA’s Fraud Detection 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.
The first in-person meeting of the Medical Audits Collaborative enabled members to dive into a myriad of technical topics associated with medical audits. Going forward, members will explore practical steps towards developing strong medical audits systems (as observed in South Korea), which they will disseminate through a practical toolkit later this year.
Specifically, members will re-convene over the next few months to deep dive into the following topic areas:
- Definitions and institutional arrangements
- Claims review data analytics (the “rules” and triggers for medical audits)
- Functional requirements related to medical audits
- Indicators according to provider payment mechanism
- On-site investigations
- Use of medical audits
The needs identified during the meeting have many synergies with existing JLN collaborative learning activities, including the Information Technology and Provider Payment Mechanisms technical initiative data analytics for monitoring provider payment collaborative. Many of the participants view the Medical Audits Collaborative as a great opportunity to build on and coordinate with these exiting initiatives of the network.