Northern Territory Audit of Surgical Mortality

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The Find a Surgeon directory is a listing of active Fellows of the Royal Australasian College of Surgeons who meet the requirements of the College's Continuing Professional Development (CPD) Program and have opted to be on the list. This list excludes retired or inactive Fellows.

 

Background
Qualified privilege
Audit process
ANZCA process
Frequently asked questions
Electronic platform - Fellows interface
Lessons from the audit
Reports and publications
Submission for Data Request
Forms
Newsletter
Seminars
Committee Meeting Dates
Contact

Background

A clinical audit is particularly relevant to the surgical specialties. It is accepted as an essential component of the evidence-based process of performance appraisal. Surgical audit is a regular, documented, critical analysis of the outcomes of surgical care. The results are reviewed by peers and used to further inform surgical practice.

The Northern Territory Audit of Surgical Mortality (NTASM) is an important initiative of the Royal Australasian College of Surgeons and its Fellowship to peer review the clinical management of deaths occurring during surgical admission in the Northern Territory. Funding for this project is provided by the Northern Territory Department of Health. 

The principal aim of NTASM is to improve the quality of healthcare through feedback and education. In order to achieve this, evidence from local audit data is required.

Feedback in individual and group formats is produced. Individual feedback is thus provided to individual surgeons and aggregate data is disseminated to all surgeons and hospitals.

Surgeons are protected by statutory immunity through Commonwealth Qualified Privilege legislation. This legislation is designed to strongly encourage clinical professionals to engage in quality and safety initiatives in order to bring about improvements in care.

Summary

The Northern Territory Audit of Surgical Mortality (NTASM) began in June 2010. It is funded by Northern Territory Department of Health. The three Northern Territory public and private hospitals currently participating are:

  1. Royal Darwin Hospital
  2. Alice Springs Hospital
  3. Darwin Private Hospital
  4. Katherine District Hospital
  5. Gove District Hospital

The Northern Territory Department of Health provides members to a NTASM Management Committee. The committee reviews de-identified, quantitative reports so it can further improve and reform health provision in Northern Territory. It follows methodology established and refined by similar projects that are concurrently running in Australian Capital Territory (ACTASM), Queensland (QASM), South Australia (SAAPM), Tasmania (TASM), Victoria (VASM) and Western Australia (WAASM). NTASM is administered from the QASM office. All audits function under the umbrella of the Australian and New Zealand Audits of Surgical Mortality (ANZASM).

ANZASM, as an audit process, fulfils the following criteria:

  1. it is independent
  2. it is external
  3. it is peer-review
  4. it is systematic
  5. it is routine
  6. it is objective
  7. it is confidential (all audits are covered by qualified privilege at a commonwealth level).

Conclusion

Fellows of the College have always had accountability through personal audits and professional excellence. These qualities have been included in the College's Continuing Professional Development (CPD) Program (members only; login required).

However, it is acknowledged that while a high level of qualitative accountability exists at an individual level, there is a need from health service providers for quantitative accountability.

This quantitative accountability and also the qualitative measures are integral to the needs of those health service providers. It is also integral to reporting information to the general public. It is anticipated that statewide reporting and quality of care can be enhanced through NTASM.

Qualified privilege

Overview

The Qualified Privilege (QP) declaration (PDF 2.1MB) encourages surgeon participation within the mortality audits by strictly protecting the confidentiality of information gained in the audit.

Via a blend of state and commonwealth legislation, the declaration prevents third parties from using data that becomes available as a result of the prescribed activity cannot be disclosed (in reports or publications) outside of the activity in a manner that identifies a surgeon. The confidentiality of the information received is protected accordingly and high-level data security procedures are maintained.

The QP declaration allows non-identifiable data to be used in reviewing and analysing surgical procedures, while information that may identify an individual requires the expressed approval of the individual being recognised.

With state and commonwealth authority, the declaration effectively allows surgeons to confidently participate in the mortality audits, knowing information they liberally divulge will be utilised exclusively for its designed professional development purpose and nothing else.

Details

The Royal Australasian College of Surgeons received approval from the Minister of Health and Ageing to declare the Australian and New Zealand Audit of Surgical Mortality (ANZASM) a "quality assurance" activity under the Commonwealth QP scheme.

QP declarations are intended to encourage participation of surgeons by protecting the confidentiality of information created as part of this activity.

ANZASM is a bi-national framework of regionally based audits of surgical mortality. Every state in Australia has its own audit. Although regionally based, all audits are covered by an over-arching QP protection that ANZASM has obtained at the national level. In some regions, state coverage is also held.

This document explains:

  1. how the national QP legislation imposes responsibilities for legal disclosure of audit-related information on both the regional audits and their related audit staff
  2. what information the regional audit is permitted to disclose to hospitals (in relation to the Commonwealth QP scheme)

NTASM is permitted to:

  1. provide annual state and hospital reports that contain aggregated, de-identified (with respect to surgeon and patient) data that will report on the following:
  2. audit participation rates for their surgeons (exception: hospitals with consultant numbers less than two)
  3. hospital specific rates of optimal or suboptimal care of patients as compared to state and national averages
  4. information about the general quality of surgical care being undertaken at that hospital, relating to all aspects of care during a surgical admission.

NTASM is not permitted to:

  1. disclose confidential information gained from audit activities to anyone other than the surgeon involved in the case or the surgeons specifically assigned to provide a peer review assessment of the case,
  2. a person who discloses information stemming from the declared activity either indirectly or directly to another person or a court of law faces a possible penalty of up to 2 years imprisonment (Section 124Y, Health Insurance Act 1973).

Important, to provide audit information to:

  1. chief executive officers, or
  2. surgical/medical/clinical directors,

at hospitals where the surgeon is practicing is not permitted by law.

However, the Federal Minister of Health may authorise disclosure of information that relates to a serious offence against a law-in-force in any State or Territory. This means:

  1. identifying information can only be disclosed with the express approval of the identified individuals.
  2. the release of any such information would be unusual and should only occur after the implications of disclosure are properly considered.

Participating surgeons in the audit are permitted to identify other practitioners involved in the case.

Please note, ANZASM in partnership with Russell Kennedy lawyers compiled the QP guide (PDF 2.1MB). For further information about the QP scheme contact ANZASM.

Audit process

NTASM is a peer-review process. Participation by consultant surgeons is a requirement of the College's Continuing Professional Development (CPD) Program (members only; login required).

To start: NTASM is notified by the hospital of all surgically-related deaths (before, during or after surgery)

Next: NTASM sends a Surgical Case Form (PDF 265KB) to the consultant surgeon linked to the case. This may be sent by post or by email if the surgeon is using the Fellows Interface.

 The Surgical Case Form is:

  1. completed by the consultant surgeon or a registrar (under supervision)
  2. returned to NTASM in the reply paid envelope (as soon as possible) or electronically using the Fellows Interface
  3. de-identified and sent to a first-line assessor (a consultant surgeon: same speciality, different hospital) for anonymous peer-review.

If a second-line assessment (case note review) is not requested by the first-line assessor, the original surgeon will be sent written feedback to this effect (and the case will be closed).

If a second-line assessment (case note review) is requested by the first-line assessor (that is, the case needs further investigation or insufficient information has been provided on the Surgical Case Form) then these steps are followed:

  1. a second-line assessor is chosen by NTASM's Clinical Director
  2. medical records are requested
  3. the second-line assessor then reviews the Surgical Case Form, the medical records and the first-line assessor's comment, before writing a one or two-page report. Note: The review is carried out and the report written in a spirit of sympathetic enquiry, providing sufficient details for a clear view of events
  4. the report and relevant feedback is sent to the original surgeon. The case is then closed
  5. at each stage of the process the original surgeon has right of reply.

ANZCA Process 

The NTASM and the Australian and New Zealand College of Anaesthetists (ANZCA) now collaborate in the collection of anaesthetic-related surgical mortality.

NTASM is notified by the hospital of all deaths that occurred during a surgical admission, see flowchart (PDF 40KB).

An anaesthetist may be involved when the treating surgeon alerts the possibility of an anaesthetic component of the death.

In which case, NTASM will send an Anaesthetic Case Form (PDF 124KB) to the treating anaesthetist for completion.

An Anaesthetic case form is:

  1. completed by the consultant anaesthetist or registrar (under supervision);
  2. returned to NTASM in the reply paid envelope (as soon as possible);
  3. de-identified and sent to a first-line assessor (a consultant anaesthetist; same specialty, different hospital) for anonymous peer review.

If a second-line assessment (case note review) is not requested by the first-line assessor, the original anaesthetist will be sent written feedback at this point (and the case will be closed).

If a second-line assessment (case note review) is requested by the first-line assessor (that is, the case needs further investigation OR insufficient information has been provided on the case form then these steps are followed:

  1. An appropriate second-line assessor is selected.
  2. Medical records are requested by NTASM project staff.
  3. The second-line assessor reviews the Anaesthetic Case Form (PDF 124KB) the patient's medical records and the first-line assessor's comment, before writing a one-page report.
    Note: The review is carried out and the report written in a spirit of sympathetic enquiry.
  4. The report and relevant feedback is sent to the reporting anaesthetist. The case is then closed.
  5. At each stage of the process the reporting anaesthetist has right of reply.

Frequently asked questions

Do I have to participate in NTASM?
Your participation in NTASM is a requirement if you are a surgeon in an operative-based practice, have a surgical death and an audit of surgical mortality is available in your hospital.

If I participate do I have to be a first or second-line assessor?
You can choose to be a first-line assessor, and/or a second-line assessor. You can participate in the NTASM without being a first-line assessor, and/or a second-line assessor.

Are any instructions/guidelines provided for first and/or second-line assessors?
Guidelines are printed on the first-line and second-line assessment forms sent to you. An example of a second-line assessment report (1-2 page) is also sent to you.

Is the NTASM process confidential?
All data and forms are de-identified. All data and forms are securely stored. NTASM reports are covered by qualified privilege.

How will NTASM know if a patient has died under my care?
NTASM is notified (regularly) of surgically related deaths that occur in 4 Northern Territory public hospitals. Notification occurs through the hospitals' medical records departments or the mortality and morbidity meetings of the hospital.

What if I need the medical records to fill out the NTASM Surgical Case Form?
Contact the medical records department of your hospital to ensure records can be located and delivered to you.

What do I do after completing the NTASM Surgical Case Form?
Please return the Surgical Case Form to QASM in the reply paid envelope provided or electronically using the Fellows Interface. Contact us if you have any questions or concerns.

Who do I contact if I have any queries?
Please contact the NTASM Project Manager.

Electronic platform - Fellows interface

ANZASM now offers an electronic submissions platform called Fellows Interface. If you do not have a username and password email the NTASM office. The paper-based submission format is still current and available.

Those who wish to take up the online option will be sent access details, and user instructions see list of user guides below:

Fellows Interface User Guide (PDF 3.1MB)
Self-generated Notification of Death User Guide (PDF 258KB)
Third Party Delegates User Guide (PDF 190KB)
Third Party Delegation - Fellows User Guide (PDF 554KB)

When submitting information to the audit office, ensure that the study ID and patient UR number are clearly labelled on all the supporting documentation.

Lessons from the audit

Lessons from the audit (members only)

Reports and publications

Annual reports

Annual Report 2010-2016 (PDF 1.53MB)
Annual Report 2010-2016 Media release (PDF 142KB)
Annual Report Summary 2010-2016 (PDF 270KB)
Annual Report 2010-2015 (PDF 2.13MB)
Annual Report Summary 2010-2015 (PDF 597KB)
Annual Report 2014
(PDF 1.7MB)
Annual Report Summary 2013 (PDF 1.6MB)
Annual Report 2013 (PDF 2.2MB)
Annual Report 2011-2012 (PDF 3.7MB)
Annual Report 2010-2011 (PDF 1.1MB)

Forms

Surgical case form (PDF 265KB)
First-line Assessment form (PDF 134KB)
Second-line Assessment form (PDF 120KB)
Consultant participation form  (PDF 180KB)
Anaesthetic case record form (PDF 124KB)
Anaesthetic participation form (PDF 86KB)
Data Request Form (PDF 195KB)

Please return form to:
QASM - Royal Australasian College of Surgeons
PO Box 7476
East Brisbane QLD 4169 Australia

Manual

Fellows Interface User Guide (PDF 3.1MB)
Self-generated Notification of Death User Guide (PDF 1.1MB)

Newsletter

Quick Bits August 2016 (PDF 18.1KB)
Quick Bits Issue 3, Jan 2015
(PDF 44KB)
Quick Bits Issue 2, Jul 2014 (PDF 218KB)
Quick Bits Issue 1, Jan 2014 (PDF 280KB)

Publications

Surgical mortality audit data validity from ANZJSurg.com, 2015
Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit
from BMJ Open, Apr 2015
Outcomes from the Northern Territory Audit of Surgical Mortality: Aboriginal deaths
from ANZ J Surg, Nov 2014
Mortality Audit of Octogenarians With Acute Cholecystitis from ANZ J Surg, Aug 2014
Mortality from acute appendicitis is associated with complex disease and co-morbidity from ANZ J Surg, Jul 2014
Teleconference fracture clinics: a trial for rural hospitals by J North (PDF 934KB)
Analysis of the causes and effects of delay before diagnosis using surgical mortality data from British Journal of Surgery, Dec 2012

Submission for Data Request

The Australia and New Zealand Audits of Surgical Mortality (ANZASM) will consider requests for data and data extracts for special reports. ANZASM is a declared Quality Assurance Activity and is required to work within specific requirements of the declaration. ANZASM must protect the confidentiality of the information it receives, to respect the privacy and sensitivity of those to whom it relates and maintain high-level data security procedures. Only de-identified data can be released.

  • Requests for data should accompanied by a reason why the analyses are required.
  • Requests should have a clear & realistic plan.
  • Requests require approval by the audit data-request subcommittee and final endorsement by the ANZASM Steering Committee.
  • Once approved, requests will be prioritised and work will proceed according to the priority list.
  • It is expected that abstracts be progressed into manuscripts within one year.
  • All publications prepared from this RACS data need to be approved by the Director of RAAS, Chair RAAS and Chair ANZASM.
  • All publications from RAAS are reported to the RACS Council.

Please email the completed data request form (PDF 195KB) to the RAAS Director, Wendy.Babidge@surgeons.org for national data extraction. Alternatively contact the NTASM Project Manager for NTASM data extracts.

Links

American Journal of Public Health
American Journal of Surgery
Annals of Surgery
Annals of Thoracic Surgery
ANZ Journal of Surgery
Anaesthesia
Archives of Surgery
Australian Prescriber
British Journal of Surgery
British Medical Journal (BMJ)
Canadian Journal of Surgery
European Journal of Vascular and Endovascular Surgery
Healthcare Quarterly
Intensive Care Medicine
International Journal of Public Health
International Journal of Surgery
Journal of the American Medical Association (JAMA)
Journal of Telemedicine and Telecare
Journal of Thoracic & Cardiovascular Surgery
Journal of Trauma
Journal of Vascular Surgery

Medical Journal of Australia
New England Journal of Medicine
Rural and Remote Health
Telemedicine Journal of EHealth

General links

Science Direct  
American Medical Association (AMA) 
Wiley 
Highwire Press
Sage Publications

Seminars

Future events

NTASM Seminar on Friday, 10 November 2017, "Captain of the ship? A surgeon's role in safety and quality". Gold Coast University Hospital.

Previous events

NTASM Seminar on Friday, 13 November 2015, "Surgery and the Obese Patient". Download program (PDF 289KB).

Presentations for this seminar can be downloaded below:

     Session 1:
        Dr John North, Mortality data looks at obesity (PDF 109KB), watch video.
        Prof David Watters, Flab: fact and fantasy (PDF 1.3MB), watch video.
        Mr Nick Steele, The role of healthcare purchasing in enabling improved patient care (PDF 495KB), watch video.
        Dr Bronwyn Thomas, Why I don't want to anaesthetise your patient (PDF 1.3MB), watch video.

     Session 2:
        Margaret Brooke, The three things every surgeon should tell their obese patients (PDF 2.8MB).
        Dr Stuart Young, Managing the morbidly obese (PDF 1.7MB), watch video.
        Dr Kevin Lee, Medical approach to obesity (PDF 10.7MB), watch video.
        Dr Gary Shepherd, Imaging the obese patient.

     Session 3:
        Dr Aisling Fleury, Obesity and the acute surgical patient (PDF 198KB), watch video.
        Dr George Hopkins, Dilemmas in weight-loss surgery (PDF 9.2MB), watch video.
        Dr Michael Donovan, General Surgery and the obese patient (PDF 554KB), watch video.
        Dr Matthew Hope, Obesity and Orthopaedic Surgery: lose weight or operate? (PDF 1.9MB), watch video.

     Session 4:
        Dr Warren Ward, Obesity: personality disorders and psychiatric illness (PDF 572KB), watch video.
        Mr Shane Jeffrey, Friend or Foe: food beliefs and weight management (PDF 1MB), watch video.
        Dr Lew Perrin, The new tsunami (PDF 1.7MB).

NT, SA, and WA Annual Scientific Meeting
, 7-8 August 2015, "Extended scope of practice for surgeons and health care practitioners generalism in surgery: Its role with the specialists". Hilton Hotel, Darwin.
NTASM Seminar on 7 November 2014, "Situational Awareness and the Surgeon". Download program (PDF 337KB). Presentation by Prof M Griggs on "Situational Awareness in Surgery". Download presentation (PDF 289KB).
NTASM Seminar on 15 November 2013, "Adverse Events - Systems or Surgeons". Download program (PDF 73KB).

Contact

All general enquiries can be directed to:
NTASM - Royal Australasian College of Surgeons
PO Box 7385
East Brisbane QLD 4169 Australia

Email: ntasm@surgeons.org
Telephone: +61 7 3249 2903 or +61 8 8922 8249 (NT only)
Facsimile: +61 7 3391 7915

Clinical Director - Dr John North
Project Manager - Therese Rey-Conde
Project Officer - Jenny Allen
Project Officer - Sonya Faint
Project Officer - Candice Postin
Administrative Officer - Kyrsty Webb
Darwin Contact - Gayle Eccles

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