Victorian Audit of Surgical Mortality

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Background 
Clinical Audit
Qualified Privilege
Audit process
Frequently asked questions
Electronic platform - Fellows Interface
Reports and Publications
Submission for Data Request
Forms
Case Note Review
Newsletter
Seminar
Committee Meeting Dates
Collaborations
Contact

Background

The Victorian Audit of Surgical Mortality (VASM) seeks to review all deaths associated with surgical care.

VASM is a collaboration between the Victorian Government's Department of Health, the Victorian Surgical Consultative Council and the Royal Australasian College of Surgeons. The VASM project is funded by the Victorian Department of Health. The VASM Management Committee meets bimonthly and oversees the project which constitutes an invaluable foundation to the running and success of the audit program. The College manages VASM through the Melbourne head office.  

All surgery carries some risk and it is an unfortunate reality that sometimes patients do not survive surgery, or die after having a surgical procedure. The majority of these deaths are not preventable and occur despite surgery to overcome a life threatening condition. In some instances however death is an unexpected outcome of surgery for a condition that is not life threatening. It is especially important that the issues surrounding death in the latter group are studied to see if similar adverse outcomes can be prevented.

Clinical audit

A clinical audit is a regular, documented, critical analysis of the outcomes of (surgical) care. It is accepted as an essential component of the evidence-base that underpins the practice of surgery. The original mortality audit was established in Scotland (Scottish Audit of Surgical Mortality). The template was adapted for the Australian environment and in 2001 gave rise to the West Australian Audit of Surgical Mortality. The Victorian Audit of Surgical Mortality (VASM) is based on the experiences of this and several other states.

This audit process is designed to gather information on factors involved in the death of patients undergoing surgical treatment. Gathering information from multiple sources over time will allow us to detect emerging trends in the outcomes from surgical care. The aim is to identify any system or process errors and develop strategies to redress these.

All information collected during the audit process is protected by Commonwealth Qualified Privilege legislation. It is therefore not possible to provide reports on individual instances of mortality to hospitals or families of deceased persons.

An annual report providing a summary of findings on all deaths will be published and be available to the general public.

Qualified Privilege

Overview

The Qualified Privilege (QP) declaration 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, 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

VASM is a peer-review process. Participation by consultant surgeons is a requirement of the College's Continuing Professional Development (CPD) Program. The audit process is initiated by notification of the death of a patient while under surgical care. The following procedure is followed:

  1. The VASM office will send a case record form to the (treating) surgeon responsible for the care of that patient and invite them to participate in the audit.
  2. Completed case record forms are returned to the VASM office.
  3. All identifying information is removed from the form.
  4. The case record form is then sent to another consultant surgeon (first-line assessor) of the same specialty but from a different hospital, for (anonymous) peer-review.
  5. The assessor gives their opinion as to the adequacy and appropriateness of management of the patient and whether the case would benefit from a more detailed review.
  6. If no further review is felt necessary, the treating surgeon will receive feedback to this effect and the case will be closed.
  7. If a more detailed review is requested or if the surgical assessor considers that insufficient information to reach a conclusion was provided on the original case record form, a more detailed review of the case will be initiated (second-line assessment).
  8. For this second line assessment a copy the patient's case-record is required. VASM will forward the original case record form with the case-notes to another consultant surgeon from the same specialty, but in a different hospital for a written review.
  9. When complete, the outcome of this review will then be fed back to the (treating) surgeon responsible for patient care.

Frequently asked questions

Do I have to participate in VASM?
Your participation in VASM 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 choose to participate in VASM, do I have to be a first or second-line assessor?
No. All surgeons participating in the audit can volunteer to be either first- or second-line assessors.

Are any instructions/guidelines provided to those who volunteer to be first or second-line assessors?
Yes, a 'Guideline for Assessors' is provided. This document suggests the principles to adopt for the peer review assessment and includes examples. Also provided is a first- or second-line assessment form for the assessor to complete.

Is the VASM process confidential?
Yes. All data is de-identified and is securely stored at the VASM office.

How will VASM know if a patient has died under my care?
VASM will be notified by the hospital's medical records department or the Coroner's Office. Alternatively, surgeons may notify VASM directly of a death of a patient under their care.

What if I require the medical case notes to fill out the VASM case record form, is there an easy way for me to retrieve them?
Yes. The medical records department of each hospital will locate medical records for you.

What do I do once I have completed the VASM case record form?
Once you have completed the case record form, please return it to VASM's dedicated PO Box in the reply paid envelope provided.

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.

The electronic option will not suit everybody yet. 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. Please contact your local audit office for further details on submitting surgical case forms online.

Reports and Publications

Media release

VASM Annual Report 2016 Media Release (PDF 42KB)
VASM Annual Report 2015 Media Release (PDF 45KB)
VASM Annual Report 2014 Media Release (PDF 37KB)
VASM Annual Report 2013 Media Release (PDF 51KB)
VASM Annual Report 2012 Media Release
(PDF 34KB)
VASM Annual Report 2011 Media Release (PDF 58KB)

Plain language statement & Executive summary

VASM Annual Report 2016 Executive Summary (PDF 202KB)
VASM Annual Report 2015 Plain Language Statement (PDF 622KB)
VASM Annual Report 2014 Plain Language Statement (PDF 961KB)

Annual reports

VASM Annual Report 2016 (PDF 1.3MB)
VASM Technical Report 2016 (PDF 1MB)
VASM Annual Report 2015 (eBook)
VASM Annual Report 2015 (PDF 3.3MB)
VASM Technical Report 2015 (PDF 770KB)
VASM Annual Report 2014 (PDF 1.6MB)
VASM Annual Report 2013 (PDF 2.8MB)
VASM Annual Report Summary 2012 (PDF 6.3MB)
VASM Annual Report 2012 (PDF 12.7MB)
VASM Annual Report Summary 2011 (PDF 782KB)
VASM Annual Report 2011 (PDF 3.1MB)
VASM Annual Report Summary 2010 (PDF 2MB)
VASM Annual Report 2010  (PDF 104MB)
VASM Annual Report 2009 (PDF 1.8MB)
VASM Hospital Report 2008 (PDF 2.6MB)
VASM Annual Report 2008 (PDF 1.9MB)

Surveys

VASM Assessor Feedback Survey (PDF 11KB)
2017 VASM Activity Survey - Fellows (PDF 151KB)
2017 VASM Activity Survey - Hospitals (PDF 131KB)

Publications

Potentially preventable deaths in the Victorian Audit of Surgical Mortality ANZ Journal of Surgery, October 2016.
Comparison of the Victorian Audit of Surgical Mortality with coronial cause of death ANZ Journal of Surgery, May 2015.
Clinical management issues vary by specialty in the VASM: a retrospective observational study BMJ Open, June 2014.
VASM is associated with improved clinical outcomes ANZ Journal of Surgery, June 2014.
Evaluating the value and impact of VASM ANZ Journal of Surgery, June 2013.

Internal evaluation

VASM activity evaluation survey report 2011 (PDF 653KB)
VASM activity evaluation survey report 2010 (PDF 534KB)

External evaluation  

ASPEX Evaluation Report on VASM July 2015 (PDF 2MB)
ASPEX Evaluation Report on VASM Nov 2011 (PDF 1.3MB)

Validation audit

VASM Validation Audit Report SLA 2013 (PDF 892KB)
VASM Validation Audit Report FLA 2013 (PDF 797KB)
Previous issues see members file.

Manual

Fellows Interface User Guide (PDF 3.1MB)

Case Note Review Booklet

Edition 9 (PDF 1.3MB)
Edition 8 (eBook)
Edition 8 (PDF 1.9MB)
Edition 7 (PDF 481KB)
Edition 6 (PDF 3.9MB)
Edition 5 (PDF 2MB)
Edition 4 (PDF 7.6MB)
Edition 3 (PDF 8MB)
Edition 2 (PDF 3.2MB)
Edition 1 (PDF 759KB)

Go to ANZASM for the National Case Note Review Booklets

Positive Assessments Booklet

Edition 1 (PDF 3.5 MB)

Newsletter

Issue 23, June 2017 (eNews)
Issue 22, Apr 2017
(eNews)
Issue 21, Dec 2016 (eNews)
Issue 20, Oct 2016
(eNews)
Issue 19, June 2016
(eNews)
Issue 18, Mar 2016 (eNews)
Issue 17, Dec 2015
(eNews)
Issue 16, Oct 2015 (eNews)

Previous issues see members file.

Audit guidelines

VASM Audit Process Timeline (PDF 24KB)
A Guide for Victorian Hospitals (PDF 1MB)
De-id Guideline for Hospitals (PDF 618KB)
Guideline for first and second line assessors (PDF 1MB)

Forms

Consultant Participation Form - RACS (PDF 75KB)
Consultant Participation Form - RANZCOG (PDF 76KB)
Notification of Death (NOD) Form (PDF 1.2MB)
Case Record Form (CRF) (PDF 737KB)
Case Record Form Functional Definitions (PDF 138KB)
First Line Assessment (FLA) Form (PDF 794KB)
First Line Assessment Functional Definitions (PDF 54KB)
Second Line Assessment (SLA) Form (PDF 789KB)
Second Line Assement Functional Definitions (PDF 55KB)
Data Request Form (PDF 195KB)

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.

Links

AOA Joint Replacement Registry
Australasian Health & Research Data Managers Association
Australasian Society for Cardiac and Thoracic Surgeons
The Australian and New Zealand College of Anaesthetists (ANZCA)
Australian and New Zealand Intensive Care Society (ANZICS)
Australian and New Zealand Society for Vascular Surgery (ANZSVS)
Clinical Registries
Department of Health, Victoria, Australia
The Haemostasis Registry
Health Issues Centre
MIG Registry
National E-Health Transition Authority
The Royal Australasian College of Medical Administrators
State Coroners Office of Victoria
Victorian Admitted Episodes Data Set (VAED)
Victorian State Trauma Registry
Victorian Surgical Consultative Council (VSCC)

Seminars

Future events

VASM Workshop on 27 September 2017, "Fellows Interface Workshop". Workshop will be held at the Royal Australasian College of Surgeons, Melbourne between 2.45pm to 5.00pm. Download program (PDF 229KB). Register here. Registrations close 20 September 2017. 

Previous events

VASM AHRDMA Annual Scientific Meeting on 16 June 2017, "Knowledge-based sharing in the health industry".  Download report (PDF 52KB).

Presentations for this meeting can be downloaded below:
          Ms Louise Shiel, Clinical trials in the community (PDF 3.3MB).
          Ms Lynne Rigg, Using data at the Women's to inform improvement (No presentation provided).
          Mrs Claudia Retegan, The value of the surgical mortality audit (PDF 908KB).
          Dr Ingrid Hopper, Australian Breast Device Registry (PDF 2.3MB).
          Ms Katie Davis, Surgery for the treatment of otitis media in Indigenous Australian children (No presentation provided).
          Ms Daliah Moss, Outcome from a research study in RACS Global Health (PDF 11.8MB).
          Dr Trisha Jenkins & Dr Paul Bertrand, Incorporating research into the RMIT Pharmaceutical Sciences placement (PDF 494KB).
          Ms Robyn deVries, A brief introduction to arty psychotherapy (PDF 4.3MB).
          Mr Nick Arvanitis, Creating a 'healthy' workforce from a mental health perspective (PDF 1.2MB).
          Ms Deborah Jenkins & Ms Nicole Newton, Data supporting the RACS Action Plan: Building Respect (PDF 300KB).
          Ms Kylie Thitchener, The building respect in practice (PDF 2.2MB).
          Ms Sue Mason, Documentation considerations for investigator initiated studies (No presentation provided).
          Dr Angela Watt, Research and governance in the health service (PDF 660KB).
          Dr Suzanne Hasthorpe, Clinical trial research regulation (PDF 150KB).
          Dr Megan Robertson, Clinical ethics in the health service (PDF 2MB).
          Dr Susan Alder, Regulatory affairs of medical devices in the health industry (PDF 585KB).

VASM Seminar on 21 February 2017, "Can registries and audits improve patient outcomes?". Download report (PDF 49KB).

Presentations for this seminar can be downloaded below:
          A/Prof Sue Evans, Australia and New Zealand Prostate Cancer Clinical Registry (PDF 828KB).
          A/Prof Paul Mcmurrick, The Bi-National Colorectal Cancer Audit (PDF 2.5MB).
          Prof Peter Cameron, The Victorian State Trauma Outcomes Registry Monitoring Group (PDF 2.9MB).
          Mr Gilbert Shardey, The Australian Society of Cardiac Surgeons and Thoracic Surgeons Registry (PDF 1.2MB).
          Prof Richard de Steiger, The Australian Orthopaedic Association National Joint Replacement Registry (PDF 3.6MB).
          Prof Wendy Brown, Australia and New Zealand Bariatric Surgery Registry (PDF 2.0MB).
          Mr Craig Murphy, BreastSurgANZ Quality Audit (PDF 1.9MB).
          Mr Barry Beiles, Victorian Audit of Surgical Mortality & Australasian Vascular Audit (PDF 867KB).
          Dr Gabby Fennessy, VMIA (PDF 7.3MB).

VASM Workshop
 on 21 October 2016, "Lessons learned from the VASM cases". Download report (PDF 41KB).

VASM Seminar
on 11 August 2016, "Would you have changed the management of this patient's course to death?" Download report (PDF 35KB).

VASM Seminar on 23 February 2016, "Improving outcomes in the surgical patient". Download report (PDF 95KB).

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

VASM Seminar on 18 February 2015, "Perioperative care. How can we do better?" Download report (PDF 73KB).

VASM Workshop on 1 May 2014, "Understanding the literature and preparing for journal submission". Download report (PDF 134KB).

VASM Seminar on 19 February 2014, "Surgical Emergencies and Shared Care". Download report (PDF 33KB).

Collaborations

VCCAMM

Expansions in the surgical mortality audits include the collaboration between the VASM and the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM).

The state-wide monitoring and reporting of anaesthesia-related mortality and morbidity by the VCAMM is based on the voluntary submission of direct reports from treating anaesthetists, or indirect reports from other medical practitioners or hospital anaesthetic departments and now from the VASM.

The VASM identifies a potential anaesthetic component to the death of the patient from Q17 ("Was there an anaesthetic component to the patient death?") from the SCF as answered by the treating surgeon. If the answer to the question is "Yes" or "Possibly" then the VASM refers the cases on a monthly basis to the VCCAMM for a further anaesthetic assessment. This process is fully covered by the ANZASM Qualified Privilege (gazetted 25th July 2016).

In the event of an anaesthesia-related death, a detailed list of documentation is then to be forwarded by the hospital to the VCCAMM within 28 days.

Upon completion of the anaesthesia-related death assessment, relevant stakeholders are provided the findings of the inquest according to the VCCAMM guidelines. During this process, the VASM is provided with a copy of the final anaesthetic assessment to close the audit loop.

RANZCOG

Developments in the surgical mortality audits comprise the inclusion of our Gynaecological colleagues into VASM with a steadily increasing number of participants. The audit is notified of all deaths occurring after a gynaecological surgical procedure. Participation by Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) Fellows is currently considered voluntary under RANZCOG CPD requirements.

 

Contact

All general enquiries can be directed to:
VASM - Royal Australasian College of Surgeons
GPO Box 2821
Melbourne VIC 3001 Australia

Telephone: +61 3 9249 1154
Fax: +61 3 9249 1130
Email: vasm@surgeons.org

Clinical Director - Mr Barry Beiles
Project Manager - Claudia Retegan
Senior Project Officer - Jessele Vinluan
Project Officer - Andrew Chen
Research Assistant - Dylan Hansen
Research Administrative Officer - Trinh Do
RMIT Placement Student - Andrew Nguyen
RMIT Placement Student - Tony Tran

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