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EDITORIALS

Received: September 9^th 2014
Accepted: October 6^th 2014

Medical audit: the beginning of a new era

Guillermo Fajardo-Ortiz,^a Karina Robles-Rivera,^b Carlos Alberto Soto-Aguilera^c

^a,b,cSubdivisión de Educación Continua, División de Estudios de Posgrado, Facultad de Medicina, Universidad Nacional Autónoma de México. México, Distrito Federal.

Communication with: Guillermo Fajardo Ortiz
Telephone: 01 (55) 5623 7254 y 5623 7253
Email: gfortiz@unam.mx

The medical audit in the Instituto Mexicano del Seguro Social was developed thanks to the physician Fernando González Montesinos, his purpose was to create a system to improve the medical services and to benefit the affiliates. In 1962 he published the first edition of the manual named “La Auditoría Médica” that described the procedure for the evaluation of medical records and medical practices. As the years passed he improved the system of medical audit and provided the basis for the current evaluation known in other terms.

Keywords: Medical care; Medical audit; Fernando González Montesinos

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Medical care in the Instituto Mexicano del Seguro Social (IMSS), and probably in other health care institutions, has had decisive times. For the Instituto, one of those times was the implementation of medical audit by Dr. Fernando Gonzalez Montesinos (1922-2004), to establish a method for the evaluation of medical services.

Fernando Gonzalez Montesinos was born in Florence, Italy. He lived in the midst of a cultured family of Mexican parents, arriving in Mexico at a young age. He was trained in middle-class schools and during his youth was absorbed in reading topics of philosophy, language, ethics, logic, and history. As a physician, he was innovative and cutting edge, trained in the years of great clinicians and medical pre-technology. He studied at the Escuela de Medicina of the Universidad Nacional Autónoma de México, was hired as a surgeon in 1946, and subsequently pursued a postgraduate course in gastroenterology, complete with a specialty fellowship at the Mayo Clinic in Rochester, Minnesota.

His passion for medical education motivated him to develop in this field until he became, on his own merits, a lecturer at various institutions, despite practicing the profession little; he held management and advisory positions in the IMSS Jefatura de Planeación y Supervisión to create and implement a system to improve health care. For the design of the system, he turned to various studies conducted by doctors from the United States, among which stand out the work of Drs Ernest Emery and Edward Martin, founders of the American College of Surgeons in 1910; and what Dr. George Gray Ward carried out at the Women's Hospital in New York in 1918. 

After several years of research, hard work, and dedication Fernando Gonzalez consolidated his ideas for the system to become operational in IMSS medical services. In May 1962, he published instructions entitled “La Auditoría Médica” ("Medical Audit"),¹ describing the objectives and procedures for the systematic review of clinical records. Although it was a brilliant idea, some doctors fearfully believed that the aim was to punish them; however, it was never the intention to retaliate against them, but to promote knowledge of the quality of their work to develop projects that allow optimization, encourage them to improve their performance, and foster a pleasant working environment between doctors and authorities.
The medical audit was divided into internal and external, both composed of highly qualified IMSS medical personnel. The internal or local audit depended on the head of each health care unit and was made up of doctors dedicated to the evaluation of records; the external or central audit was done by the Subdirección General Médica. Each audit was supposed to make sure that clinical records had clinical history, progress sheets, requests for laboratory and clinical tests with their respective results, referrals from within and outside the health care unit, and requests for surgery when necessary. The evaluation forms were on ‘mimeographed’ papers, and consisted of checklists to be completed according to the presence or absence of documents and items.

The internal and external groups performed the audit using medical records, seeing if they were legible and complete; if they were not, the reason was given why it could not continue. They checked if progress notes were related to the clinical history and the presence of notes of referral to medical specialties. After the review of each element of the clinical record, they would be assigned a score whose total should be 100 points, which decreased in case of mistakes or omissions. The information obtained was individually registered and maintained by the directors, who revealed them to the personnel involved.

The utility of the medical audit was quick to reveal invaluable information to identify needs of the enrolled patients and health professionals in order to create continuous quality improvement programs for the medical services provided at IMSS. Soon voices of satisfaction of managers and doctors were heard, and in their turn, of enrollees, being the beneficiaries of the implementation of the new system; this made IMSS a leader in quality of care.

Two years later, the second edition of "La Auditoría Médica" instructions were published,² which managed to implement the evaluation system throughout the Instituto. With his collaborators, in 1976 he published in the IMSS Boletín Médico the piece “Observaciones a través de la evaluación del expediente clínico en el Instituto Mexicano del Seguro Social” ("Observations through clinical record evaluation in the Instituto Mexicano del Seguro Social "),^3-5 declaring the main problems encountered in the medical records of clinics and hospitals in order to focus on them and fix them.

It is impossible today to think of the quality of health care in Mexico, without mentioning the contributions of Dr. Fernando Gonzalez Montesinos, who made the difference in the way medical services were provided at IMSS. Medical audit managed to impact other organizations of the health sector with its good results, in Mexico and other countries, who decided to implement the same system in order to benefit the health and welfare of their members and provide doctors with tools for improvement. When thinking about the technology of the time, one might ask: What changes and how far would Gonzalez Montesinos have come with his assessor system if he had used digital technology tools? And would hospital accreditation and certification be conceived of in the same way?

References

1. Instituto Mexicano del Seguro Social; Subdirección General Médica; Departamento de Planeación Técnica de los Servicios Médicos. La auditoría médica. Primera edición. México: IMSS; 1962.
2. Instituto Mexicano del Seguro Social; Subdirección General Médica; Departamento de Planeación Técnica de los Servicios Médicos. La auditoría médica. 2da edición. Ciudad de México: IMSS; 1964. p. 5-18.
3. Maqueo P, Pérez JJ, Lee AF, González F. Observaciones al través de la evaluación del expediente clínico en el Instituto Mexicano del Seguro Social. Primera parte. Bol Méd IMSS. 1976 Ene;18(1):18-22.
4. Riva C, Aizpuru E, Limón R, González F, Lee AF, Pérez JJ. Observaciones de la evaluación del expediente clínico en el Instituto Mexicano del Seguro Social. Segunda parte. Bol Méd IMSS. 1976 Feb;18(2):60-5.
5. Hernández F, Mogollán R, Elizalde H, Pérez JJ, Lee AF, González F. Observaciones a través de la evaluación del expediente clínico en el Instituto Mexicano del Seguro Social. Tercera parte. Bol Méd IMSS. 1976 Mar;18(3):86-9.

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