The audit process

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

It is a requirement to participate in the Australian and New Zealand Audit of Surgical Mortality for all consultant surgeons in operative-based practice, has a surgical death and an audit of surgical mortality is available in the surgeon's hospital.

1. Participation as an assessee may be required.
2. Participation as an assessor remains voluntary and highly recommended.

The hospital notifies ACTASM of all deaths that occurred during a surgical admission.

ACTASM sends a Surgical Case Form to the treating surgeon linked to the case. The treating surgeon or a registrar (under supervision) completes the form and returns it to ACTASM (at each stage of the process the treating surgeon has right of reply).

Note: If the case does not fit the inclusion criteria for the audit, it can be excluded at this point and the case is closed.

ACTASM sends de-identified information to a first-line assessor (consultant surgeon, same specialty) for anonymous peer review. The first line assessor reviews the case using the Assessment Guideline (PDF 269.48KB) and returns their professional assessment to ACTASM. As part of the review process, the assessor will identify if there was sufficient information to make an accurate review, if there are any areas that require further review and offer feedback on the case.

If there was sufficient information and there were no areas for further review, ACTASM staff send the written feedback to the treating surgeon (at each stage of the process the treating surgeon has right of reply) and the case will be closed.

If there was insufficient information or further review was requested:

1. ACTASM project staff request the medical records
2. The hospital provides the medical records
3. ACTASM project staff send the de-identified records to a second-line assessor (consultant surgeon, same specialty)
4. The second-line assessor reviews the Surgical Case Form and the medical records and completes a one-page report using the Assessment Guidelines. (PDF 269.48KB)
5. Note: This is undertaken in the spirit of sympathetic enquiry and must provide sufficient details for a clear view of events
6. The second-line assessor returns all of the documentation to ACTASM
7. ACTASM will send the report and feedback directly to the treating surgeon (at each stage of the process the treating surgeon has right of reply) and the case will be closed.