Medical audit and total quality management in health care: a sociological assessment

Changes in the organization, funding and delivery of health care are affecting health systems in all societies in the search for greater economy, efficiency and effectiveness. The issue of quality is at the forefront of these changes and has been largely addressed by the implementation of the Medical Audit initiative. Medical Audit is the review of clinical practice, a process largely designed by doctors, led by doctors and, described as an issue that is essentially a matter for the medical profession. Nevertheless, since its formal introduction, the initiative has largely failed to meet expectations. Some argue that the problem is technical in character, that audit methods are inadequately researched. Others believe that the philosophy of Total Quality Management, designed to effect continuous improvement in all aspects of health service delivery, is more appropriate. However, this study, conducted through participation and observation of both the audit process and implementation of Total Quality Management in health care, will argue that, in their current form, neither is adequate for fulfilling its stated objectives. It will suggest that Medical Audit is conceptually rather than technically inadequate, because little account is taken of the complex social and technical systems that exist within hospital settings. Similarly, the industrial model of 'total quality' presupposes conditions that do not exist within provider organizations. Nevertheless, this is not to say that Medical Audit and Total Quality Management are inappropriate for health care. Audit has demonstrated only limited success and, though many of aspects of the 'total quality' approach are clearly relevant, it will require modification and further testing prior to full implementation. Both audit and 'total quality’ require fundamental changes in behaviour, and if they fail, they may not get a second chance - health care quality is much to important for that to be allowed to happen.