21 / 66
19
Figure 6: Hospital origin of cases that could not be reviewed due to non-participation by treating surgeon.
Note: total n=1,402.
Audit period 1 July 2007 to 30 June 2015.
Only hospitals with cases of a count of >=0.5% have been included in this analysis.
Comments:
•
Surgeons electing not to participate in 2014–2015 were concentrated in only a few hospitals.
•
In each instance the hospital had agreed to participate by notifying deaths to the VASM. However, the responsible
treating surgeons had not returned the SCFs and thus the audit process could not be completed for those cases.
Hospital Clinical Governance Reports
6.4.
•
The VASM released the first series of the national individualised Hospital Clinical Governance Reports in
November 2014 and the second series has been rolled out in February 2016. The VASM and the ANZASM
identify clinical management issues via independent peer review assessments to actively manage and improve
patient safety. The audit developed strategies to redress these issues. This HCGR report uses a comprehensive
data set that can assist accreditation of hospitals for certain National Safety and Quality Health Service (NSQHS)
Standards such as; Standard 1 - Governance for Safety and Quality in Health, Standard 3 - Healthcare Associated
Infections, Standard 6 - Clinical Handover, Standard 9 - Recognising and Responding to Clinical Deterioration in
Acute Health Care and Standard 10 - Preventing Falls and Harm from Falls.
•
The VASM has rolled out the HCGRs in February 2016 with de-identified and aggregated data. These reports
enable benchmarking and monitoring of clinical management trends within a hospital as well as comparisons with
other participating peer-grouped hospitals, both within the region and nationally. The HCGR can be presented and
discussed at hospital clinical governance committee meetings, audit of surgical mortality management committee
meetings, with the local health network (or similar) representative, as well as with hospital quality managers and
DHHS representatives. Non-participation of Fellows and poor completion of the case record form diminishes the
value of these quality assurance reports.
•
The VASM currently is in the process of enhancing the Individual Surgeons Report and the Hospital Clinical
Governance Reports, and has the objective of producing summarised Clinical Governance Reports that would
highlight any problems hospitals may have.
•
The RACS Research, Audit and Academic Surgery Division of RACS (through ASERNIP-S) is currently carrying
out a review on “What makes a good Morbidity & Mortality meeting’ and aims to produce a booklet with
educational guidelines and a checklist that will followed by a formal RACS position paper on the topic.
•
Hospitals routinely ask for evidence of CPD and Mortality Audit compliance. The RACS will provide the
confirmatory documentation of this to the surgeons concerned and the relevant Director of Clinical and/or Medical
Services (if requested).
0.0% 0.5% 1.0% 1.5% 2.0% 2.5%
127
129
131
165
172
181
192
197
205
Non participant cases during the audited period (%)
Hospital identifier
11
Hospital sites impacted
2007-2014
9
Hospital sites impacted
2014-2015