3°COHORTE MÓDULO 3 SEMANA 2: clase sincrónica Prof. Facundo Romero

Main ideas and lessons from the class (Module 3, Week 2: Synchronous session — “Auditing in Health Sciences”)

1) Purpose and framing of the session

• The instructor positions the course as essential for understanding the complexity of professional practice in health auditing.
• Emphasis is placed on formality, standardization, continuous improvement, and data-driven management rather than purely punitive or subjective auditing.

2) Who the participants are (speaking roles)

• The class includes a lead professor/instructor plus synchronous student introductions from different health roles and provinces (doctors, nurse, pharmacist), each describing their auditing context.

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Methodologies and concepts taught

3) Core auditing approach: reduce subjectivity via process standardization

• Problem identified: recurring audit errors (e.g., contracts not updated; debit/expense-recovery management issues), even with digitization.
• Method: establish standardized processes approved by top management and known by staff.
  • Aim: remove “we do it this way because it’s always been done” culture.
• Debit management concept:
  • Debits happen; the goal is not “zero debit” but measuring and improving through indicator-based control.
  • Use dashboards/indicators (e.g., balanced scorecard, “smart organizations”) to track progress toward targets.

4) Data and measurement: audit requires decision-making, not just data collection

• Key rule: “Do we measure everything?” → No. Measurement must be tied to precise questions/points and how the organization will use the data.
• Decisions should be based on:
  • indicators,
  • evidence,
  • analysis,
  • and team interpretation.

5) “Smart/Intelligent organizations” in health: what they are and how they work

• Definition concept: an intelligent health organization adapts to change through continuous learning and knowledge management—not just through technology.
• Important clarification: implementing the “best” software or digital tools is insufficient if:
  • staff don’t properly complete/use systems,
  • reporting is unclear,
  • and the culture does not support improvement.
• Core characteristics listed:
  • Adaptability (respond quickly to regulatory, epidemiological, technological changes)
  • Continuous learning / continuous improvement processes
  • Knowledge management and innovation
  • Collaborative culture and teamwork
  • Staff training and scheduled learning plans
• Cultural barrier addressed: staff resistance to change.
  • Mitigation: education, training, and communication so staff understand “why” and how change improves outcomes.

6) Organizational learning process (team-based improvement cycle)

The instructor describes organizational learning as a structured loop:

• Identify the problem
  • If no problem identification → cannot address it.
• Generate solutions as a team
  • Solutions should be based on evidence, experience, and teamwork.
• Implement changes
  • Adjust protocols
  • Add new technologies or methodologies
  • Healthcare is described as dynamic; processes can’t remain static.
• Evaluate results
  • Measure and analyze indicators
  • Provide feedback
• Outcome: continuous improvement—each iteration moves performance toward the highest attainable standard.

7) Deming cycle (plan–do–check–act) as a practical tool

• Apply to any field/workplace:
  • Plan: define what to do and how
  • Do: execute the plan
  • Check/Verify: confirm what was done matches the plan
  • Act/Improve: implement improvements based on findings
• Emphasis: standards/processes become inactive if not reviewed every 4–5 years.

8) Root-cause analysis tool: “Fishbone / ‘Why’ diagram”

• Purpose: analyze causes of adverse events/near misses and determine root causes.
• Structure:
  • Problem statement at the “head”
  • “Bones” list cause categories
  • Repeated “why” questioning builds the root cause
• Example cause-and-fix logic given:
  • If surgical biosafety checklist isn’t followed → possible causes:
    • lack of adherence to regulations → due to lack of training or missing regulations
  • If people enter surgery without barriers → possible cause:
    • no physical/process barrier → solution: build barriers + reinforce training/dissemination

9) Patient safety and patient experience as measurable responsibilities

• Safety isn’t only clinical:
  • The “first victim” is the patient.
  • The “second victim” can be healthcare staff.
  • Even when it isn’t technically an adverse event, harm can still occur (e.g., psychological stress like cancelled surgery).
• Patient experience is treated as part of quality management:
  • Use patient satisfaction surveys and complaints data for process improvement.
  • Examples of survey-driven issues: waiting room comfort, waiting time, surgery suspension logistics, appointment cancellations.

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Detailed instruction: health contracts (types and implications for auditing)

10) What a health contract is (definition)

• A formal written agreement that creates a legal link between parties (e.g., insurer/financier and provider/“lender”).
• It establishes:
  • conditions of operation,
  • obligations and rights,
  • service scope (covered vs not covered),
  • exception mechanisms,
  • payment method by agreement type.

11) Types of contracts described and how auditing should consider them

• Service provision contract

  • Provider offers a specific service for a defined payment.
  • Common in Argentina with independent providers/private clinics for specific or one-off procedures.
  • Advantage: precise scope/coverage definition and payment.
  • Risk: overutilization (if control/auditing is weak).
  • Auditing focus: ensure procedures are well-controlled to minimize overuse.

• Capitation contract

  • Fixed monthly payment per affiliated person (per registry).
  • Common in prepaid programs and agreements between social security organizations and clinics.
  • Advantage: cost control for the health security agent.
  • Risk: severe underutilization.
  • Auditing focus: use indicators to verify whether services are under- or over-provided.

• Comprehensive service contracts

  • Agreement covering a complete set of services with continuity of care.
  • Seen in chronic care programs and public hospitals (including decentralized management).
  • Auditing focus: verify continuity and performance; note that expense recovery processes may be missing or non-standardized in some settings.

• Subcontracting contracts

  • A primary provider delegates part of services to third parties.
  • Provider retains overall/global responsibility to the insurer/funder.
  • Advantage: expands service offer without primary provider investing in everything.
  • Risk: loss/decrease of control if the structure isn’t well designed → increased risk of financial loss and management failures.

• Health network contracts

  • Agreements integrating multiple providers under one contractual framework and entity.
  • Used across multiple care levels and geographical locations.
  • Advantage: continuity of care across centers; presence across regions.
  • Risk: requires complex coordination and trained resources.
  • Auditing focus: alignment with parent organization’s vision/mission/values and standardization across centers.

• Public contracts

  • Contracts with state bodies under public procurement regulations (tenders/specifications usually).
  • Constraints noted: more bureaucracy → delays in hiring/hiring processes → need to track bureaucracy/time indicators.

• Home care contracts (home hospitalization/assistance)

  • Agreement to provide medical, nursing, or therapeutic care at patient home.
  • Used for chronic, post-surgical, reduced mobility patients, and cases where institutional hospitalization isn’t required.
  • Advantages: can improve quality of life due to environment/family context.
  • Key requirements: social worker and psychologist reports to confirm home conditions are suitable.
  • Main disadvantage: logistics complexity (install equipment, coordinate professionals).

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Communication and formality: an auditing requirement

12) Why “formality” matters

• Auditing and health management require formal documentation because:
  • legal/compliance implications exist,
  • informal channels generate issues.
• Claim: many institutions rely on WhatsApp for interdepartmental communication, but it is “least formal” and can cause problems.
• Solution direction: adopt formal channels (institutional email, letters, official documentation).
• Active rules concept:
  • rules must be written, approved, known by staff, accessible, and periodically reviewed.
  • Active rules eliminate subjectivity and ambiguity.

13) Adverse event / incident reporting as part of learning culture

• Reporting should be:
  • seamless (sometimes using QR-coded anonymous forms),
  • non-punitive in spirit (as a learning mechanism),
  • used to prevent recurrence and measure improvement.
• Cultural obstacle: staff may avoid reporting due to fear of sanctions or blame.
• Correct approach: reporting as an opportunity for improvement with feedback loops.

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Practical examples referenced

• A dialysis center achieving international accreditation through a two-year quality program:
  • compliance improvements,
  • more staffing shifts and expanded capacity,
  • mortality reduction toward targets using dashboards and process standardization.
• Examples of patient safety failures:
  • failure to use surgical checklist properly (using markers to indicate wrong/needed leg)
  • patient confusion/fatigue from repeated identity checks before surgery (presented as avoidable safety risk)
• Examples of “cost of non-quality” becoming measurable:
  • malpractice settlement amounts described as indicators that quantify harm/expense
  • an institution discovering cost of poor quality could equal “about a month of the institution’s life.”

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Key concluding points

• Medical auditing in health is framed as essential for ensuring:

  • quality,
  • efficiency,
  • safety, across all healthcare service areas.

• Contracts provide formal/legal structure defining rights, obligations, service scope, and payment logic.

• Intelligent organizations and organizational learning enable continuous improvement by:
  • adapting,
  • standardizing processes,
  • training staff,
  • coordinating teams,
  • and using data to act.

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Speakers / sources featured

1. Prof. Facundo Romero (main instructor / course professor)
2. Dr. Sarmiento (present as supportive/introducing participant; briefly acknowledged)
3. Dr. Diego Gracia Guillén (source of a quoted phrase about excellence/goal not fully reachable but pursued via bioethics)
4. Dr. Jesús Montenegro (author mentioned; co-authored chapter on quality/efficiency/effectiveness in peritoneal dialysis)
5. Dr. Ramón Carrillo (quoted about poverty/sadness/misfortune and microbes—“poor causes”)
6. Dr. René Favaloro (quoted about respect for patient and ethics—“science and conscience… humanity”)
7. Dr. Orlando Franks (student participant; doctor from Mendoza)
8. Javier (student participant; doctor from Tucumán; works with post-anesthesia recovery unit/URPA and audits)
9. Andrea (student participant; pharmacist; works with pharmaceutical supplies and retrospective billing audits)
10. Lucía González (student participant; nursing degree; works in health auditing and high-cost medications)
11. Gustavo (mentioned as previously involved in auditing/theoretical part; also linked to specialization)
12. “Eli” (host/moderator name referenced during class interactions; also called “doctor” at times)