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data. Variability in the quality and completeness of patient records submitted by hospitals remains an area of criticism
received from second-line assessors. This is an area VASM will monitor as it is crucial in obtaining a useful report.
Along with other jurisdictions we have consistently identified the following clinical risk management issues as ongoing
areas for improvement:
•
delay in diagnosis and treatment, including better detection and management of the deteriorating patient
•
poor communication between health professionals, especially for coordination of patient care, and
•
decision to operate rather than palliate.
The VASM is very aware of the importance of data accuracy. The clinical data is entered by the audit team using
Read Codes, but as this is not performed by clinicians, unintentional errors have occurred in the past. Over the past
year all data entry forms have been checked by the clinical director prior to entry into the database. This will result in
accurate data capture which allows for meaningful clinical reports.
The VASM also has initiated an extra step in the audit process as a pilot study, whereby the treating surgeon is given
a form after receiving the assessor reports. This allows the clinician with the best grasp of the clinical nuances of the
case to fill in the gaps identified by the assessors or add information that allows better perspective on the course to
death. In 67.4% (145/215) of instances the treating surgeon indicated on the feedback evaluation form that the peer
review assessment was a good source of information to improve surgical care at their institution. This new process
has proven to be very instructive.
Conclusion
The success of the VASM is dependent upon participating surgeons and hospitals, and a highly efficient, motivated
and hard-working team at the RACS.
Despite the existence of this audit, it has been observed that the same type of issues occur repeatedly; driving VASM
to refocus on the educational role to disseminate lessons learnt and recommendation messages across to clinicians
and using the HCGRs to drive further improvements.
The support of the Victorian State Government, the Victorian Department of Health and Human Services (DHHS), the
Victorian Surgical Consultative Council (VSCC), the Australian Health Practitioner Regulation Agency, the Australian
Commission on Safety and Quality in Health Care, the Victorian Managed Insurance Authority, RANZCOG and RACS
has facilitated VASM’s progress.
Yours sincerely,
Mr Barry Beiles MB.BCh, FRACS (Vasc)
Clinical Director, VASM