The Leader Medical Audit in Hospital Routine Resource

Introduction

Currently, about US$7 trillion had spent on health costs by all governments and citizens worldwide and the remuneration that governs the activity of the medical market has called Fee for Service. This means that payment is made by the number of services provided or by productivity, with major conflicts of interest between the actors (maintenance companies, operators, providers and beneficiaries), with regulatory agents such as the National Health Surveillance Agency and the National Agency Supplementary Health System playing important roles. However, due to the high costs, the maintenance companies and operators increasingly need an on-site analysis have carried out in hospitals, rear and home care in an attempt to contain and reduce the cost. Besides that, it is important to promote significant results for patients and the community.

Among the several factors that compete for the increase in health costs is the increase in the migratory population due to several causes that do not account for and absorbed by the countries triggering the appearance of diseases that are already extinct. Also, it is worth including the age of the population that needs more medical care due to the higher incidence of events in this age group. The change in the epidemiological profile of the population affected by a series of chronic diseases that require continuous monitoring for periods of years or decades as neoplasms, persistent infectious diseases, non-infectious diseases of long duration, some mental disorders, sequels (TBI, stroke, myelitis) and other causes.

The increase in Supplementary Health costs due to the use of resources above the patient’s need for assistance makes private medical assistance unfeasible and, consequently, increases the demand of the Unified Health System. With the 2017 annual review in several health sectors, it was possible to assess the importance of the role of medical auditing. It is necessary to rely on the analysis of accounts, extensions with relevant discussions between the visiting (external) auditor and the internal auditor to promote a simultaneous audit that uses ‘evidence-based drugs’ and IT tools as a tool. In this case, the objective is only to achieve cost reduction, but also to guarantee the quality of the services provided.

To better understand this situation and collaborate with relevant reflections, the proposal of this work is justified by the scarcity of academic studies related to Health Economics with the implementation of internal audits in the hospital environment. Therefore, the general objective of this work is to make public health professionals aware of the importance of applying the medical audit service as an effective tool in helping to manage the technical resources used according to the needs of patients. For this, we search for the most relevant publications on the topic, which concern the concept of auditing in health administration and a specialised auditor in this area, in addition to explaining the fundamentals and steps of health auditing to analyse the real need for consultations, procedures or application of hospital supplies. The highlight was due to the main models currently applied, according to the researched authors, to indicate the paths to be followed in hospital institutions, either by internal authorship or by outsourcing this service.

In this sense, we could see that, in most organisations, the focus on generating results and increasing profitability for its shareholders has related to the sales areas as generators of results, with the supply areas remaining as the generators of expenses, that is, the ‘Villains’ of organisations that only accumulate expenses. This concept is very noticeable in many organisations when, for some internal or external reason, they need to reduce costs. The supply areas are usually the most targeted part of the employees who end up fired. However, if we look at it from another point of view, we will realise that it is precisely this department that can generate important results and much more quickly, causing significant impacts in terms of profitability of organisations in the short and medium terms.

The challenge imposed is to find a formula to maximise these opportunities in the areas of supplies, identifying, negotiating, contracting, and implementing these cost reductions. This process includes mapping, measuring and prioritising these opportunities in terms of supply. How is it possible to improve results within the shortest possible time and maintain these benefits over time and in an integrated way with the routine of organisations? In other words, what would be the most effective way to create new supply solutions and develop new relationships with suppliers, without compromising the level of quality required by already established standards? These questions need precise and well-prepared answers.

To begin with, we need to consider that all expenses of an organisation or its segment are subject to the acquisition of inputs so that it is possible to create an action strategy so that they can be contracted. It should be noted that, of the organisation’s total expenses, there are exceptions that can be impacted by projects of greater scope, capable of increasing physical changes, negotiations with government agencies, and access to resources in regions that are outside the area of ​​activity of the institutions.

We can start the Spending Diagnosis by a Flowchart of the Macro Strategic Planning activities to carry out a structured process, as showed above (Bim, 2016; see Figure 1).

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Figure 1.

Strategic Planning: Expense Diagnosis.

Materials and Methods

From a methodological point of view, the work sought to elaborate bibliographic research on the most recent publications that address the theoretical and practical concepts related to the implementation of Strategic Sourcing programs in the field of health, more specifically in large hospital institutions of high and medium complexity. For this purpose, books, academic articles, online journals and specific websites at global and national levels have analysed to explore the theme and outline the state of the application of this tool in reducing costs. Given the challenges to face for that, it is possible to revert this business practice into significant financial benefits capable of improving the quality of healthcare, in particular for people who depend only on the health unic system.

Results

In health, it is essential to monitor all costs resulting from the services and actions developed. A recognised difficulty in the economic assessment concerns the need to calculate the unit cost of the activity or procedure. Costs also relate to the consumption of everything that is incorporated into the product (Tanaka & Melo, 2001). In any administrative activity, cost control determines the systematic analysis of variations, both in their numerical aspect and in the reasons that have determined them. Thus, cost analysis is essential for the control of health programs.

In this sense, we must consider all the factors involved in the processes in question. In addition to costs, an important factor is the appropriate use of resources, that is, through planning, coordination, direction, and control. In assessment procedures, the indicators provide visualisation of trends and results of the factors to be analysed. Through hospital indicators, it is possible to assess whether hospital programmes and services are positively influencing health and the population, while also showing the quality and quantity produced. In this study, the indicators that measure the degree of health were used (Moraes, 1994). An important calculation for the evaluation of health issues is mortality, which can be analysed through the Mortality Information System, made available by the Ministry of Health and the State Department of Health.

The term audit appeared for the first time in the field of occupational health through the physician George Gray Ward, in the United States, in 1918, when it was possible to verify the quality of medical care provided to patients through medical records. From the historical point of view, the systems have focused on control, mainly on costs and, it contributed to this scenario by prioritising production information quantitatively and financially. It is worth remembering that the practices, structures, and instruments for controlling, evaluating and auditing health actions have always been mostly associated with billing.

From a conceptual point of view, the audit in this area was proposed by Lambeck in 1956. Its premise is ‘assessment of the quality of care based on direct observation, registration and the clinical history of the client’. Thus, we can explain the audit in Health as a set of activities developed both for control, in the case of an operational audit, as for the evaluation of specific aspects and of the system, which is up to the analytical audit. The first works in carrying out activities aimed at controlling the actions developed by the service delivery network, focusing on the conditions of the physical network, on the regulatory mechanisms, and the development of health actions. The second one, on the other hand, has focused on the development of activities that aim to deepen the analysis of quantitative assessment concerning the quality of healthcare services provided to the community.

In the Fabro et al. (2020) view, the audit can focus on the health sector as a whole or a specific segment of the sector. The audit has incorporated into the routine of health institutions to assess the qualitative aspects of the assistance required by the patient, the internal processes and hospital accounts, aiming at reducing the financial loss or even restructuring the services. For the author, the audit is part of a whole as one of the stages of the health management process. He allows a systematic evaluation of assistance to measure the results of assistance as well as analyse its costs. It has the potential to provide information that supports the reaffirmation of successful measures and the reordering of inappropriate actions in the assistance and financial sphere.

According to Fabro et al. (2020), ‘there are currently a large number of hospitals, predominantly private, that have audit services that rely on the performance of health professionals’. By applying the principles and tools of medical auditing for more effective and economical management of organisations that provide services in the health area to ensure that the use of an integrated management system will give greater control to the processes, thus generating fewer errors and more credibility and speed of information. Therefore, it is expected that an audit system brought by health unic system aim to collaborate and ensure the improvement of the quality of care, as well as the integrality of care, promoting equal access to all citizens, going beyond the provision of necessary service.

Decree no 1,651 of 9/28/1995 (art. 4) SNA comprises ‘the bodies that are instituted at each level of government’ intending to exercise control over health actions and services in each sphere of government management health unic system, according to its attributions. For the National Health Surveillance Agency, health auditing is a systematic and independent examination to determine whether activities related to quality and its results are under the planned provisions whether they have been implemented and whether they are adequate to achieve the objectives proposed by the regulatory agency. It is worth remembering that health unic system has been financed with resources from the three spheres of government. It is the constitutional responsibility of the municipal, state, and federal public authorities to allocate a portion of their budget to health actions and services. It consists of the social security budget (employers ‘contributions on payroll, billing, and profit, workers’ and revenue from forecasting contests) and the fiscal budget of the Union, states, and municipalities, the health unic system has evolved in recent years, becoming a health policy, with new forms of financing assistance. The control and auditing systems, mainly in the state and municipal components that have related in a direct way to service providers must follow this evolution steadily.

In this case, billing is directly related to the use of information, it is necessary to introduce a programme for the evaluation of primary care, as well as the achievement of public service goals that include management evaluation indicators, the so-called nosological and epidemiological profiles of the population that serve as a basis for the assistance programming and organisation process. Also, it is necessary to promote the triggering of social control actions and financial transfer. In this sense, it is important to note that payment for the production of services is only one of the ways of remunerating services, the oldest and most criticised by managers and service providers.

In the financial resources contract, the component with a fixed monthly value and a component with variable value must be present, according to the achievement of the goals established in terms of physical and quality goals, plus the component that corresponds to the production of services. In the case of a Goals contract, the rights and duties of the contractor and the contractor have been explained. The important thing is to determine the expected results in the care provided by the establishment; thus establishing the quality indicators and the productivity goals to achieve.

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Pillars of Quality	Quality Approach
Efficiency	Ability to promote improvements in health and well-being. It means what can be done in the best conditions.
Effectiveness	Ability to promote improvements in health and well-being in real conditions.
Efficient	The cost measure is used to achieve health improvement. That is, if two care strategies are equally effective or effective, the one with the lowest cost is the most efficient.
Optimisation	The relevance when the effects of care are valid not only in absolute terms but relative to the costs of care. Refers to the cost-benefit ratio.
Acceptability	The adaptation of care to the wishes, expectations, and values of patients and their families. It refers to the patient’s relationship with the professional, accessibility to care, and its amenities.
Legitimacy	Acceptability from the point of view of the community and society.
Equity	It refers to the fair distribution of care and benefits among members of a population.

Source: Donabedian (2002).

In the case of auditing with a focus on quality, we must also consider the use of instruments based on standards of assistance, indicators, parameters, among other facilitators of its operationalisation, so it can develop based on references structured by the scientific literature. Quality assessment, by eliminating unnecessary and potentially harmful procedures to the patient, as well as preventing some aspects such as nosocomial infection, has been considered as a way to moderate the total costs (Caleman & Moreira, 1998).

It was also possible to notice that, nowadays, a movement focused on quality, including on the part of health operators, which, through audits, evaluate the quality of the assistance provided in the institutions they hire to revalidate contracts, adapt price lists, and assess whether the level of assistance is in line with its principles. The trend of health auditing, around a mixed conception of cost control and quality improvement, maybe being demanded by a panorama of restructuring health production demarcated by a new management logic of health organisations, called Attention Managed.

As the principle of auditing in the health area has focused on assessing the quality of care provided to the patient, this must be the crucial point for the practice of health professionals. Therefore, quality in healthcare consists of obtaining the greatest benefits with the lowest risks for the patient and the lowest cost. In the strict performance of the auditing of accounts, there is also the opportunity to verify irregularities in the assistance work process, which can express the loss of its quality, which generates unnecessary expenses and rework. As the main source of data for the auditor, the evaluation of the patient’s medical record has demonstrated the gap between the theory and practice related to the record, compromising information on the assistance provided, which can cause general ethical and administrative problems (Chiavenato, 2003).

About the types of audit in Health, we have Operational Audit, which works by comparing the level of assistance provided in contrast to acceptable standards of assistance. In this case, the indicators measured are the performance evaluation, the patient’s medical record, and a questionnaire answered by the patient or other instruments that fulfil this objective. In the retrospective audit, the data recorded on the patient’s chart have been compared to the pre-established standards. They have as indicators the patient’s chart and the work options based on the number of charts to work on:

First option = Up to 50 discharges/month, all records are worked/above 50 discs/month, 10% of records are worked.

The second option = Working with all medical records after drawing lots.

- Administrative instruments for registration (reports) and control (rules and routines).

In the case of the form of the intervention, the Internal Audit has been carried out by professionals from the institution itself, whereas the External Audit has been carried out by professionals who do not belong to the institution and they have hired for this purpose, that is, using outsourcing work. Concerning the Mixed Audit, a committee has usually formed with the professionals of the institution itself and the specialists hired who are not part of it. In this context, the processing time can be continuous, when the process has performed in predetermined periods, starting from the ending point of the previous analysis, or periodic, when it has been performed in certain periods, but without the commitment to continuity of the process (Cerchiari & Erdmann, 2008).

As for the character, we have the Preventive Audit, which can be implemented so that the procedures have been audited before they happen. In general, it has related to the sector for the release of procedures or health plan guides, which can be exercised by doctors and other professionals in the area. In the case of the operational audit, the procedures used to be audit during and after its completion since the auditor works together with the healthcare professionals to monitor the clinical status of the inpatient, to assess the source and the way of managing the inpatient (Cerchiari & Erdmann, 2008). Thus, the auditor may indicate, in agreement with the physician or other health professionals responsible for the care, another option for the user, such as Home Care (modality of healthcare service with home care), or even o Chronic Case Management partially remotely (Araujo, Simões & Silva, 1978).

Analytical auditing, on the other hand, has been related to the analysis of data collected by preventive and operational auditing through comparison with management indicators and with other organisations’ indicators. In this process, auditors must have knowledge related to health and administrative indicators, including the use of tables, graphs, databases and contracts. This will ensure that they can gather the information related to the health plan, as well as the problems detected in each service provider in that area. Finally, the audit of accounts presents itself as a thorough process that verifies the medical diagnosis and that of other professionals, the procedures performed, the exams and their reports, the materials and medicines spent according to the medical prescription. Ii includes the correct times, the various hospital fees, reports of the multidisciplinary team, besides standards of the Hospital Infection Control Commissions, among other complementary procedures.

We can also identify three different methods for understanding the process and dynamics of care provided to patients, considering the entire context of care. They have been defined as the method of retrospection through which it is possible to verify past facts, placing the observation in a certain context that previously occurred. The analytical or prospective method allows the evaluation of assistance together with the patient since the work is not only for verification but also for the interpretation and interaction with the facts. The concurrent method in which retrospect has been used for the development of the process as a whole.

Discussion

From the content exposed here, we can observe that the audit service and the hospital’s management aim to outline the corrective actions, with the installation of negotiations between hospital managers and suppliers to improve the quality of care. For that, it is necessary to establish objectives, collect and analyse the data and information of the assistance during the hospitalisation until the moment of discharge, analyse the structure, the process, and the result for the integrated evaluation and prepare the technical report so that the actions that will guarantee the improvement of the service as a whole. It also reformulates inappropriate practices and the indication of in-service education through negotiations between hospital managers and health plans to prove payments, question, and review disallowances.

About the origin of the data/information for the audit process in the record of assistance in the patients’ medical records, in the procedures and routines manuals in the assistance standards, in the patient’s medical records, and the documents related to hospital costs, it is necessary to establish a program of direct observation of assistance. It includes planned interviews with patients and their families, besides professionals inserted in the structure as active agents in the process to obtain positive results (Cerchiari & Erdmann, 2008).

It is important to note that technological advances, which already have much software for billing, will generate an even greater demand for the auditor’s work to assess, contextualize and show where the problems are, as well as the most intelligent and responsible way to indicate the measures to contain and control hospital expenses. This vision of the account at the tip of the pencil is a privilege of knowledge of auditors, both doctors and nurses.

The experts explained that the technological advances that already have much software for the realisation of billing, which will generate even greater demand for the auditor’s work to assess, contextualise, and show where the problems are, as well as the most intelligent and responsible to indicate the measures to contain and to control hospital expenses. This view of the bill at the tip of the pencil, according to them, is a privilege of the auditor’s knowledge, both doctors and nurses.

Therefore, it is not enough to say that there is remuneration based on the value in health, when it is not possible to arrive at the basis of the operation to understand how the billing has charged and from that, to be concerned with the outcome of the quality with patients have treated. Only a well-trained and specialised auditor in healthcare can predict, as he knows how to achieve the best results. This is the auditor’s profile that today’s society needs.

Conclusion

After this discussion, we can say that health auditing plays an extremely important role in our country and must accompany the constant evolution that new management models that technologies allow. For this, it is necessary to face the health audit with a new look capable of seeing beyond the simple function of making calculations that indicate what must be cut to meet the goals set. Thus, the list of remuneration models must consider a series of aspects that assess the complexity of this service in the current context of the globalised economy, since the role of the auditor gains a new configuration in this process. It acts as an interface agent between suppliers and hospital managers’ decision-making regarding the possibilities in terms of purchasing all types of inputs to guarantee quality service to the majority of the Brazilian population, which depends on health unic system.

To conclude, we emphasise that, even with the humanised and more amplified view of audit activities, risks are an inherent part of healthcare, whether public or private. However, through training and the establishment of internal and internal partnerships promoted by a process committed to the well-being of patients and professionals involved, these risks can and should be managed most economically and competently possible, to minimise uncertainties for all those who are part of this service network. In the public network, concerning private hospitals, the possibilities for substantial changes are more restricted and limited due to the criteria already established by the administration in all government spheres.

Even so, there are always new paths to be discovered and to trace towards building and strengthening transparent relationships at all levels of hierarchy, which prioritise qualified and valuable hospital care for patients, observed in their context and their particularities in clinical terms, since each case requires a specific approach for the results to achieve. It is also worth remembering that, in the case of this research work, there were no ethical and interest conflicts because it is a bibliographic survey on the proposed theme to obtain current information that led to a more critical and comprehensive reflection on the importance and the main characteristics of the auditor’s social role in public health.