Charles Shaw, in a number of articles and his Hospital Handbook (Shaw, 1989, 1990) has played a key role in outlining the principles of medical audit. He arbitrarily divides the process of medical audit into four phases. The philosophical phase which seems to have been negotiated, is whether the medical profession should be involved; the organisational phase; who should lead the process, and the resources required; the practical phase, what should be audited and the methods used; and the invasive phase, how the general concepts and the details of audit are communicated through publication. He goes on to describe a variety of methods of audit including the review of adverse events and general statistics, the assessment of randomly selected records, and finally the review of a topic (which includes medical record review). Another approach in planning audit is through understanding of the organisation itself (Donabedian, 1966) and evaluating quality of care in terms of the structure of the organisation (bricks and mortar, staffing, beds, technology etc.), the process of care, and this may include length of stay, broad out-patients statistics, and perhaps more controversially, face to face contact, group interaction, home visits, day hospital attendance and so on. Finally, and most complex, is outcome.
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