Context

This publication was produced within the context of the health system reform in Egypt. The Health Insurance Organization (HIO) was restructured with the intention of becoming an « effective health care services enterprise able to design, price, negotiate, contract, and pay for services covered under the social health insurance scheme ».

A medical audit system was then established, as a key component of this new strategy, with the aim of :

 Ensuring that the facility and other health care entities with which it contracts continuously fulfill their contractual obligations
 Ensuring that purchased health care is medically necessary, appropriate, accurately and completely documented in the medical record
 Ensuring that its beneficiaries receive safe health care and provided in a healthy environment
 Ensuring that its beneficiaries receive the best quality of care.

Contribution

Most of the care quality and medical facilities auditing standards are broadly accepted ; the guidelines can be adapted and/ or used in other countries health facilities.

These guidelines clearly introduce the audit process to auditors. The purpose is : « to help them carry out their roles and responsibilities in both primary health care facilities and hospitals ».

They are also helping to define the qualifications and duties of the auditors and the audit process. Moreover, the document could be used in trainings and as a consistent guide to firm up details of auditing standards.

Content

This guide is divided into two parts :

 Guidelines for auditing primary health care facilities
 Guidelines for auditing hospitals.

For each part, there are two main sections :

 Medical audit guidelines in compliance with HIO contracts. This section provides guidelines on how to audit and score each article of the contract.
 Medical audit guidelines in compliance with Egyptian Ministry of Health selected accreditation standards that are relevant to HIO.