Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

CRITERIA BASED AUDIT

POLICY & PROCEDURE

YASHODA HOSPITAL
MALAKPET
Page 0 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

POLICY
Yashoda Hospital shall, from time to time, conduct audits based on the criteria (Criteria-based
Audits) provided by Consultants of various departments
PROCEDURE
The Department of Medical Audit shall conduct Criteria-Based Audits on a regular basis. Each
phase of audit shall be three months (quarter). 30 files (10 files each month) for each criterion, at
a minimum, shall be considered for each phase, and at any given point of time, at least 20
departments shall be under audit for at least one criterion.
1. DEPARTMENTS/SPECIALTIES CONSIDERED
The departments considered for criteria-based audit shall include, but not limited to, the
following:
1. Cardiology
2. Critical Care
3. CT surgery
4. Emergency Medicine
5. Endocrinology
6. Gastroenterology
7. General Surgery
8. Gynecology & Obstetrics
9. Internal Medicine
10. Medical Oncology
11. Nephrology
12. Neurology
Page 1 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

13. Neurosurgery
14. Orthopedics
15. Pediatrics
16. Pulmonology
17. Radiation Oncology
18. Radio Diagnosis
19. Surgical Gastroenterology
20. Surgical Oncology
21. Urology
22. Nursing
23. Dietetics
24. Medical Administration
25. Physiotherapy
2. CHOOSING AND PRIORITIZING TOPICS
The Criteria-based Audits are undertaken for the purpose of Quality Improvement and Quality
Assurance. Criteria-based audit resources will be restricted to projects with measurable standards
and criteria that are expected to deliver improvement and assurance according to agreed
organizational priorities.
3. SELECTION OF CRITERIA & SETTING STANDARD & EXCEPTIONS
1. Criteria-based audits involve measuring clinical practice against predetermined standards
(evidenced based and ideally taken or adapted from sources including national or
international guidance recommendations) of best practice. Standards are an agreed

Page 2 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

statement of best practice which will improve the quality of care; they will usually be
broken down into measurable criteria with an expected level of compliance
2. This ensures that the standards of care being audited are consistent and in line with
current evidence based practice.
3. The criteria for the audit shall be selected by the Consultants and the Clinical Audit
Department. The Chief Medical Audit Officer shall approach the Head of the Department
of each specialty to choose the criteria.
4. Each time a criterion is chosen, it shall be included into the already existing Yashoda
Criteria Bank
5. The basis for the selection of criteria shall be depending on the outcome of the
assessment of factors which include, but not limited to, the following:
a. Areas of high cost, volume or risk to patients or staff
b. Evidence of serious quality problems (E.g. patient complaints or high incidents rates)
c. Potential for impact on health outcomes
d. Topic relates to a recently introduced treatment protocol
e. Good evidence available to inform standards i.e. National Clinical Guidelines
f. Problem concerned is amenable to change
g. There is opportunity for involvement in a national audit project
h. The topic is pertinent to national policy initiative
i. There are potential collaborators who could contribute to the project workload
6. Upon choosing the criterion, the concerned Consultant and/or the Head of the
Department shall set an appropriate standard at which the said criterion would be in
compliance
Page 3 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

7. Upon setting the standard, the concerned Consultant and/or the Head of the Department
shall set exceptions for the set criterion
4. DATA COLLECTION METHODLOGY
A. Collection of IP Numbers: Depending on the criterion, the Clinical Audit Managers shall
collect the relevant IP numbers from various sources. The sources of IP numbers shall include,
but not limited to, the following:
1.

Admission Registers of Emergency Medicine Department

2.

Admission Registers of all the Wards

3.

Admission Registers of all Intensive Care Units

4.

Admission Registers of Operation Theater

5.

Preexisting Structured Formats

B. Data Collection: The Clinical Audit Managers shall collect data on preexisting structured
formats (Data Collection Sheets) designed by the Department of Clinical Audit. There shall be a
separate Data Collection Sheet for each criterion.
Upon data collection, the Auditors/Data Entry Operators shall enter the collected data, on
the Data Collection Sheets, into excel sheet.
5. DATA ANALYSIS & DOCUMENTATION OF THE FINDINGS
The Chief Medical Audit Officer (CMAO), once in a quarter, shall conduct data analysis using
standard statistics. Upon conducting analysis, he/she shall document the findings. The
documented findings shall include, at the minimum, the following:
1.

Compliance of the criterion, under audit, with the set standard

2.

Non-compliance of the criterion, under audit, with the set standard

3.

Possible reasons of non-compliance

Page 4 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

4.

Mistakes/deficiencies identified

5.

Comparison of the results with the previous three quarters

6. SUBMISSION OF REPORT
The Department of Clinical Audit, on a quarterly basis, shall submit the completed report to the
Medical Administration and the concerned Head of the Department who has chosen the criterion,
for necessary Corrective Actions
7. CAUSE ANALYSIS
Upon submission of the report, the Department of Clinical Audit, the Medical Administration, and
the concerned department which has chosen the criterion, with cooperation & coordination, shall
conduct a Cause Analysis and identify the accurate causes of non-compliance with the criterion
standard
8. CORRECTIVE ACTIONS
The Medical Administration shall meet with the concerned Head of the Department and ask to
take Corrective Actions, should there be a need. The Corrective Actions may include, but not
limited to, the following:
1.
Special education and training to the concerned staff
2.
Continuous quality improvement programs
a.
Implementation of the standard established protocol
b.
Continuous education programs
c.
Peer review of case sheets
3.
Should it be required, make necessary changes to the existing CriteriaBased Audit Policy
4.
Make modifications to the existing Criteria-Based Audit Policy
5.
Recommendations for change of practice by department(s) in general and
6.

Consultants, Registrars, DNBs, & DMOs in specific (if required)

Change the methodology of conducting the Criteria-Based Audit Policy (if

required)
9. SUBMISSION OF REPORT TO THE DEPARTMENT OF QUALITY
a. Upon Corrective Actions, and approval by Medical Administration, the Department of
Clinical Audit shall submit the report to the Department of Quality on a quarterly basis.
Page 5 of 7

Criteria-Based Audit Policy

Yashoda Hospital, MALAKPET

10. REVIEW OF THE REPORT BY THE DEPARTMENT OF QUALITY

a. The Department of Quality shall review the aforementioned report and ensure that the
changes recommended (if any) are in compliance with the internal policies of Yashoda
Hospital, MALAKPET, and the external law.
b. Should any changes, modifications be required, the Unit In-charge of the Department of
Quality shall communicate with the Head of Clinical Audit of that Unit to resolve the
issue
11. DATA SAFETY (PRIVACY, CONFIDENTIALITY, & SECURITY)
1. Upon submission of the report, all the Data Collection Sheets shall be destroyed
immediately
2. Electronic records will be retained by the Clinical Audit Department for a period of 5
years minimum.
3. All criteria-based audit data shall be stored securely in password protected files on YH
portal and comply with the organizations Information Security system.

Page 6 of 7