Tasmanian Audit of Surgical 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
Forms
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 Tasmanian Audit of Surgical Mortality (TASM) is an external, independent peer process that reviews the clinical management surrounding deaths that occurred during surgical admission when patients are admitted under consultant surgeons as well as in-hospital deaths where an anaesthetically related component to the death may be a possibility.

TASM is a joint initiative between the Royal Australasian College of Surgeons that provides office resources for this project and the Tasmanian Department of Health and Human Resources fund all other resources required. The TASM Management Committee oversees the project which constitutes an invaluable foundation to the running and success of the audit program.

The principal aim of TASM is to improve the quality of healthcare through feedback and education. In order to achieve this, evidence from local audit data is required. TASM commenced data collection in September 2004.

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) has been designed to encourage 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 Qualified Privilege (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:

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

provide annual state and hospital reports that contain aggregated, de-identified (with respect to surgeon and patient) data that will report on the following:
audit participation rates for their surgeons (exception: hospitals with consultant numbers less than two)
hospital specific rates of optimal or suboptimal care of patients as compared to state and national averages
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:

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,
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:

chief executive officers, or
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:

identifying information can only be disclosed with the express approval of the identified individuals
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

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

To start: TASM is notified by the hospital of all deaths that occurred during a surgical admission or where there is deemed to be the possibility of an anaesthetic related component to the death.

Next: TASM sends a Surgical Case form (PDF 254KB) to the treating surgeon or anaesthetist linked to the case.

A Surgical Case Form or Anaesthetic data collection form is:

completed by the consultant surgeon, anaesthetist or their registrar (under supervision)
returned to TASM in the reply paid envelope (as soon as possible)
de-identified and sent to a first-line assessor (a consultant surgeon or anaesthetist; 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 or 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 Surgical Case Form then these steps are followed:

an appropriate second-line assessor is selected
medical records are requested by TASM project staff
the second-line assessor then reviews the Surgical Case Form or Anaesthetic data form, 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, providing sufficient details for a clear view of events.
the report and relevant feedback is sent to the original surgeon or anaesthetist. The case is then closed.
at each stage of the process the original surgeon has right of reply.

ANZCA process

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

TASM is notified by the hospital of all deaths that occurred during a surgical admission, see flowchart (PDF 54KB).

There are two situations when an anaesthetist may be involved. Firstly, when the treating surgeon alerts the possibility of an anaesthetic component of the death or, secondly, when the death occurs within 48hrs of the anaesthetic's being administered.

In either case, TASM will send an Anaesthetic Case Form (PDF 98KB) to the treating anaesthetist for completion.

An Anaesthetic case form is:

completed by the consultant anaesthetist or registrar (under supervision);
returned to TASM in the reply paid envelope (as soon as possible);
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).

An appropriate second-line assessor is selected.
Medical records are requested by TASM project staff.
The second-line assessor reviews the Anaesthetic Case Form (PDF 98KB), 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.
The report and relevant feedback is sent to the reporting anaesthetist. The case is then closed.
At each stage of the process the reporting anaesthetist has right of reply.

Frequently asked questions

Do I have to participate in TASM?
Your participation in TASM 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 TASM without being a first-line assessor, and/or a second-line assessor.

Is the TASM process confidential?
All data and forms are de-identified. All data and forms are securely stored.
TASM reports are covered by Commonwealth Qualified Privilege.

How will TASM know if a patient has died under my care?
TASM is notified (regularly) of deaths that occur by the medical records departments of participating hospitals.

What if I need the medical records to fill out the TASM Surgical Case Form or Anaesthetic Data 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 us.

What do I do after completing the TASM Surgical Case Form or Anaesthetic Data Form?
Please return the Surgical Case Form to TASM in the reply paid envelope provided.
Contact us 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 2.1MB)
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

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 1.1MB) 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

VASM-TASM Seminar on 12 July 2018 on "Unexpected death - What now?". This seminar will be held between 4pm - 6pm in the Lecture Theatre, Launceston General Hospital, Launceston, TAS 7250. Download program (PDF 212KB).

Previous events

TASM Seminar on 3 November 2017, "How can registries and audits improve patient outcomes - a Tasmanian perspective?" 12.30pm to 2.00pm, Keith Milligen Lecture Theatre, Royal Hobart Hospital. Download report (PDF 50KB).

TASM Workshop on 11 August 2016, "Would you have changed the management of this patient's course to death?" 03.00pm to 5.00pm, Launceston General Hospital, Tasmania. Download report (PDF 35KB).
Presentations for this seminar can be downloaded below:
          Dr Amanda Young, General Surgery: Too many cooks (PDF 130KB).
          Mr Nigel Broughton, Orthopaedic Surgery: Can we do better? (PDF 661KB).
          Mr Stephen Brough, Urological Surgery: Can we change the outcome? (PDF 79KB).

TASM Workshop on 16 October 2015, "Would you have changed the management of this patient's course to death?". Download program (PDF 1.3MB) and download report (PDF 56KB).

Contact

All general enquiries can be directed:
TASM - Royal Australasian College of Surgeons
147 Davey Street
Hobart TAS 7000 Australia

Telephone: +61 3 6223 8848
Fax: +61 3 6223 5019
Email: tasm@surgeons.org

Project Manager - Ms Lisa Lynch

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