Collaborating Hospitals Audit of Surgical Mortality in NSW CHASM

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Collaborating Hospitals Audit of Surgical
Mortality in NSWCHASM

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What is CHASM?

• Peer review of all surgical deaths
• Will provide de-identified aggregated statistical
  data to RACS national audit
• Joint project of
• NSW State Committee, RACS
• CEC
• NSW Health
• Area Health Services

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Aims

• For Surgeons
• Review of all deaths associated with surgical
  care in NSW
• Provide a participating surgeon with timely
  feedback of opinions and suggestions from their
  peers
• Provide aggregated data of a surgeons reported
  cases
• Provide aggregated data by Area, speciality and
  facility.

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Aims

• For Health Care
• To provide information to influence changes in
  surgical practice focused on quality and safety.
• Identify trends to individual clinical unit
  activity
• Identify trends and potential system improvements
  at facility, state and national levels
• Provide feedback data to supplement peer review
  programs

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Population of Jurisdictions
Australia 20,701,488
Scotland 5,116,900
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NSW Area Health Services
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Population of NSW AHSs
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Characteristics of AHSs 2005
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Jurisdictions v NSW AHS
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CHASM

• Conducted jointly
• Clinical Excellence Commission (CEC)
• NSW State Committee of RACS
• Similar projects
• Scotland,
• WA, SA and Tasmania
• Analogous to anaesthesia (SCIDUA)
• Overseen by CHASM Committee in NSW
• Special privilege under S23 of the Health
  Administration Act (1982) for all Committee
  functions. Assessors and participants are part of
  that activity
• Reports to the Minister for Health
• This project is managed by surgeons for surgeons!

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Inclusions and exclusions

• Inclusions
• Death during admission where surgical procedure
  performed
• Non-operative death (admission under surgeon but
  no procedure performed)
• Death within 30 days of a procedure
• Coronial notification
• Exclusions
• Dead on arrival
• Palliative care
• NFR orders (notify but exclude)

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How will it work?

• Voluntary, opt-in notification by surgeons
  (participating surgeon by agreement even if no
  deaths)
• First phase 1st quarter in 2008
• Sydney West AHS
• Hunter-New England AHS
• Second phase Roll-out to all health services
  areas by end of 2008
• Third phase Anticipated private sector hospitals
  participation

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How does it work?

• Based on SASM and WAASM
• data base constructed with same business rules
• close links with admin and IT staff of both
• Similar to programs in other jurisdictions of
  RACS
• Independent
• Across whole state and 8 AHS
• Individually supported by GMCT, CEC, CGUs and
  CHASM Committee
• Will be able to export aggregated de-identified
  data

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Who does what?

• Identification
• CGU or facility will identify deaths routinely
  and will notify CHASM office (? and surgeon)
• Surgeon may identify and notify CHASM office
• Coroner may notify death to CHASM office
• Notification
• Clinical audit manager will coordinate
  notification to CHASM with CGUs etc
• CHASM will notify participating surgeon, send and
  receive completed Surgical Case Form (SCF)
• De-identification
• Hospital/surgeon identifiers are removed at CHASM
  office
• SCF sent to 1st line assessor

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1st Line Assessment

• The first line assessor is a surgical peer for
  specialty and region, not from the same hospital
• Anonymous
• Assessment made on the surgical case form to
  ascertain any
• 1) areas for consideration
• 2) areas of concern or,
• 3) adverse events
• 80-85 will require no further action!
• 1st Line Assessment form returned to CHASM
  Secretariat, entered and coded

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1st Line Assessment

• An area for consideration is where the assessor
  believes areas of care COULD have been improved
  or different, but recognises that it may be
  debatable
• An area of concern is where the assessor
  believes that areas of care SHOULD have been
  better
• An adverse event is an unintended injury caused
  by medical management rather than the disease
  process, which is sufficiently serious to cause
  prolonged hospitalisation or impairment or
  disability, or which contributes to death

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2nd Line Assessment

• In 15-20, when possible deficiencies of care are
  identified or where there is insufficient detail
• Case notes review by second line assessor
• Anonymity not possible, but data is privileged
  and protected
• Form completed with free text constructive
  comments on changes in practice to prevent a
  recurrence and returned to CHASM (one A4 page
  maximum)
• These must be considered by CHASM Committee
• Participating surgeon will receive confidential
  feedback by letter from the CHASM Committee

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Participation?

• By signing up to participate
• Will improve communication and ensure
  notifications
• By agreeing to be a 1st Line Assessor
• Better understanding of the process
• on line education
• By agreeing to be 2nd Line Assessor
• Not anonymous
• 2 or 3 per year at most
• Please use the form in your information pack and
  reply-paid envelope (pictured)
• RACS CME points under negotiation

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Does it work?

• Scottish ASM (gt10 yrs) demonstrated
• Reduction in deaths associated with adverse
  events
• Reduced delays in transfers
• Fewer missed surgical diagnoses
• Improved use of DVT prophylaxis
• Increased availability of HDUs
• Establishment of specialist surgical units
• www.sasm.org.uk

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Whats in it for surgeons?

• Each death is reviewed by a peer and feedback
  provided in a confidential and timely manner
• You have the opportunity to contribute to a RACS
  / CEC audit as a participating surgeon and/or 1st
  or 2nd line assessor.
• Time spent on the audit contributes to your CME
  points for RACS Recertification (Category 3), 1
  point per hour.
• You can confidently state, if necessary, that all
  deaths under your care are independently audited.
• Reappointment process for VMOs

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Management of Outliers
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CHASM Committee

• 18 members
• Oversee the pilot project
• Oversee the state wide program rollout
• Ministerial appointments to end of 2009
• RACS NSW State Committee Chair is the Deputy
  Chair

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CHASM Committee

• A/Professor Michael Fearnside, Chairman
• Dr Peter Holman, Deputy Chairman ex-officio
• (Chair NSW State Committee RACS)
• Prof Cliff Hughes, CEO Clinical Excellence
  Commission
• Dr Kim Hill Clinical Governance
• Dr Charles Pain Clinical Governance
• Dr Tony Eyers, General surgeon
• Professor Allan Spigelman, General
  surgeon/Research
• Dr Lewis Chan, Urologist
• Dr Warwick Stening, Neurosurgeon
• Dr Charles Fisher, Vascular surgeon

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CHASM Committee

• Dr Shane Waddell, Orthopaedic surgeon
• Dr Hamish Foster, Orthopaedic surgeon (rural)
• Professor Stephen Deane, Trauma and General
  surgeon
• A/Professor Peter Zelas, General surgeon
• Dr Mauro Vicaretti, Vascular surgeon
• Dr Allysan Armstrong-Brown, Anaesthetist
• Professor John Hilton, Forensic pathologist
• Professor Belinda Bennett, Professor Health Law,
  University of Sydney
• Dr Graeme Beaumont (Airline systems expert)

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Other factors

• Eventually part of the RACS bi-national audit
• In NSW, there will be de-identified and
  aggregated data reported to
• AHSs
• NSW Health and the Minister for Health
• An annual report will be published (CEC)
• Funded and supported by CEC, where the office
  will be situated and de-identified data stored
• CEC/GMCT funded Clinical Audit Manager (CAM) to
  assist AHSs with collection and processing of
  data, and where possible, cardiac surgery
  database and other AHS audit activities

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Participation by Speciality
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Thank-you

• Contacts
• CHASM Secretariat1st Floor, Administration
  BlockSydney Hospital Sydney Eye Hospital8
  Macquarie St, SYDNEY NSW 2000
• PO Box M25, Camperdown NSW 2050
• Tel [phone]
• Fax [phone]
• Email chasm_at_cec.health.nsw.gov.au
• Web www.cec.health.nsw.gov.au/moreinfo/chasm.html