South Australian Audit of Perioperative Mortality

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Background
Qualified privilege

Audit process
ANZCA process
Frequently asked questions

Electronic platform - Fellows interface

Reports and publications

Submission for Data Request
Case Note Review
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 South Australian Audit of Peri-operative Mortality (SAAPM) 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 South Australia. Funding for this project is provided by SA Health. The SAAPM Management Committee meets twice a year and has oversight of the project which constitutes an invaluable foundation to the running and success of the audit program.

The principal aim of SAAPM 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.

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 which 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 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. As of July 2007, 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)
  3. what information the regional audit is not permitted to disclose to hospital (in relation to the Commonwealth QP scheme)

The regional surgical mortality audits are 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.

The regional surgical mortality audits are 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, providing 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

SAAPM is a peer-review process. Participation by consultant surgeons is a requirement of the College's Continuing Professional Development (CPD) Program.

To start: SAAPM is notified by the hospital of all deaths that occurred during a surgical admission (before, during or after surgery).

Next: SAAPM sends a Surgical Case Form (PDF 253KB) to the treating surgeon linked to the case.

The Surgical Case Form is:

  1. completed by the consultant surgeon or a registrar (under supervision)
  2. returned to SAAPM in the reply paid envelope (as soon as possible)
  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 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 Surgical Case Form) then these steps are followed:

  1. a second-line assessor is selected
  2. medical records are requested by SAAPM project staff
  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-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 SAAPM and the Australian and New Zealand College of Anaesthetists (ANZCA) now collaborate in the collection of anaesthetic-related surgical mortality.

SAAPM is notified by the hospital of all deaths that occurred during a surgical admission, see flowchart (PDF 91KB).

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

In which case, SAAPM will send an Anaesthetic Case Form (PDF 125KB) to the treating anaesthetist for completion.

An Anaesthetic case form is:

  1. completed by the consultant anaesthetist or registrar (under supervision);
  2. returned to SAAPM 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 SAAPM project staff.
  3. The second-line assessor reviews the Anaesthetic Case Form (PDF 125KB), 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 SAAPM?
Your participation in SAAPM 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 SAAPM without being a first-line assessor, and/or a second-line assessor.

Are instructions/guidelines provided for first and/or second-line assessors?Guidelines are provided. They 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 SAAPM process confidential?
All data and forms are de-identified. All data and forms are securely stored.
SAAPM reports are covered by Commonwealth Qualified Privilege.

How will SAAPM know if a patient has died under my care?
SAAPM is notified (regularly) of deaths that occur by the medical records departments of participating hospitals and by a centralised state-wide data source through SA Health.

What if I need the medical records to fill out the SAAPM Surgical Case Form?
Contact the medical records department of your hospital to ensure records can be located & delivered to you. If you require assistance with this, please contact the SAAPM office.

What do I do after completing the SAAPM Surgical Case Form?
Please return the Surgical Case Form to SAAPM in the reply paid envelope provided.
Please contact the SAAPM office if you have any questions or concerns.

Electronic platform - Fellows interface

ANZASM now offers an electronic submissions platform called Fellows Interface. The paper-based submission format is still current and available. The new interface allows Fellows to self-report, complete and transmit surgical case and first-line assessment forms securely online.

The Fellows Interface is an "either/or option"; you can only use the online or paper system. If you wish to change from one to the other we will have to be notified to make the necessary changes.

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)

The paper-based submission format is still current and available. When submitting information to the audit office, ensure that the study ID and patient UR number are clearly labelled on all the supporting documentation.

Reports and publications

Annual reports

SAAPM Annual Report 2015 (eBook)
SAAPM Annual Report 2015 (PDF 4.2MB)
SAAPM Annual Report 2014 (PDF 2.21MB) and SAAPM Annual Report Overview 2014 (PDF 472KB)
SAAPM Annual Report 2013 (eBook)
SAAPM Annual Report 2013 (PDF 8.10MB)
SAAPM Annual Report 2012 (eBook)
SAAPM Annual Report 2012 (PDF 4.8MB)
SAAPM Annual Report 2011 (PDF 2MB) 
SAAPM Annual Report 2010 (PDF 1.9MB)
SAAPM Annual Report 2009 (PDF 1.4MB)
SAAPM Annual Report 2008 (PDF 8.4MB)
SAAPM Annual Report 2007 (PDF 4.7MB)
SAAPM Annual Report 2006 (PDF 192KB)

Case note review

SAAPM 2010 - Volume 3 (PDF 1.1MB)

Go to ANZASM for the National Case Note Review Booklets

Newsletter

Oct 2016 (eNews)
Jun 2016 (eNews)
Mar 2016 (eNews)
Dec 2016 (eNews)
Aug 2015 (PDF 448KB)
May 2015 (eNews)
May 2015 (PDF 339KB)
Feb 2015 (PDF 171KB)
Nov 2014 (PDF 301KB)
Aug 2014 (PDF 274KB)

Forms

Surgical Case Form (PDF 253KB)
First-Line Assessment Form (PDF 107KB)
Second-Line Assessment Form (PDF 107KB)
Anaesthetic Case Record Form (PDF 125KB)
Data Request Form (PDF 195KB)

Manual

Fellows Interface User Guide (PDF 3.1MB)

Publications

Potentially avoidable issues in neurosurgical mortality cases in Australia ANZ Journal of Surgery, Apr 2016.

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 regional audit of mortality manager for regional data extracts.

Seminars

Future events

Future SAAPM seminars will be posted here.

Previous events

SAAPM Seminar  on 25 October 2016, "End of life matters". Download the program (PDF 714KB).
Presentations for this seminar can be downloaded below:

        Mr Glen McCulloch, Introduction and opening remarks (PDF 176KB)
        Prof Ian Olver, Ethics of non-treatment (PDF 196KB)
        A/Prof Sarah Thompson, General Surgery (PDF 2.4MB)
        Mr Michael Berce, Vascular Surgery (PDF 266KB)
        Dr Greg Rice, Cardiothoracic Surgery (PDF 2.3MB)
        Mr Stephen Santoreneos, Neurosurgery (PDF 606KB)
        Dr Christopher Beare, Perioperative Physician's perspective (PDF 362KB)
        A/Prof Mary White, Intensive Care perspective (PDF 2.1MB)
        Dr Chris Moy, End of life care basics (PDF 4.7MB)
        Dr Christine Drummond, Tales of a porcupine (PDF 398KB)
        Prof Ian Olver, Communication (PDF 168KB)

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. For more information  email the SAAPM office.

SAAPM Seminar  on 23 July 2015, "The decision to operate - or not". Download the program (PDF 671KB). Presentations for this seminar can be downloaded below:

Mr Glenn McCulloch Introduction and 10 years of SAAPM (PDF 359KB)
Dr Ivan Ward Pre-operative assessment, watch video (PDF 3.6MB)
Dr Greg Rice Risk prediction in Cardiac Surgery, watch video (PDF 2.7KB)
Mr David Hill P-POSSUM exposed, watch video (PDF 148KB)
Prof Robert Fitridge Predicting outcomes in Vascular Surgery - when not to operate, watch video (PDF 1.7MB)
Dr Katy Gibb Saying 'No'- a physician's perspective, watch video (PDF 258KB)
Dr Jennie Louise Futility and the ethics of saying 'No', watch video (PDF 221KB)
Dr David Evans High risk procedures - an ICU perspective,  watch video (PDF 1.9MB)

SAAPM Seminar on 28  February 2012, "Recognising the deteriorating patient". Download the program (PDF 161 KB).

Contact

All general enquiries can be directed to:
SAAPM - Royal Australasian College of Surgeons
PO Box 3115
Melbourne Street
North Adelaide SA 5006

Telephone: +61 8 8219 0914
Fax:  +61 8 8219 0999
Email: saapm@surgeons.org

Clinical Director - Mr Glenn McCulloch
Project Manager - Sasha Stewart
Project Officer - Kimberley Cottell

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