[Audit as a tool to assess and promote the quality of medical records and hospital appropriateness: metodology and preliminary results]

In the actual economic context, with increasing health needs, efficiency and efficacy represents fundamental keyword to ensure a successful use of the resources and the best health outcomes. Together, the medical record, completely and correctly compiled, is an essential tool in the patient diagnostic and therapeutic path, but it's becoming more and more essential for the administrative reporting and legal claims. Nevertheless, even if the improvement of medical records quality and of hospital stay appropriateness represent priorities for every health organization, they could be difficult to realize. This study aims to present the methodology and the preliminary results of a training and improvement process: it was carried out from the Hospital Management of a third level Italian teaching hospital through audit cycles to actively involve their health professionals. A self assessment process of medical records quality and hospital stay appropriateness (inpatients admission and Day Hospital) was conducted through a retrospective evaluation of medical records. It started in 2012 and a random sample of 2295 medical records was examined: the quality assessment was performed using a 48-item evaluation grid modified from the Lombardy Region manual of the medical record, while the appropriateness of each days was assessed using the Italian version of Appropriateness Evaluation Protocol (AEP) - 2002ed. The overall assessment was presented through departmental audit: the audit were designed according to the indication given by the Italian and English Ministry of Health to share the methodology and the results with all the involved professionals (doctors and nurses) and to implement improvement strategies that are synthesized in this paper. Results from quality and appropriateness assessment show several deficiencies, due to 40% of minimum level of acceptability not completely satisfied and to 30% of inappropriateness between days of hospitalization. Furthermore, there are great discrepancies among departments and among Care Units: the higher problems are centered in DHs, which are generally lacking on both profiles. Finally, our audit model, that could be considered a good project according the NHS (score of 20/25), has allowed to involve in 34 editions 480 professionals of different care Unit which are satisfied and stimulated to keep going in continuous improvement of the quality and appropriateness with these arrangements. The tools used in the project have proven their value for measuring the minimum quality of healthcare documentation and organizational appropriateness: furthermore, the audit has been shown as an effective methodology for their introduction because it ensures their acceptability among the staff and creates the basis for a rapid and quantifiable improvement that, through the promotion of accountability and transparency, could support the risk management activities and ensure greater efficiency in hospitalization.