SCOTTISH AUDIT OF SURGICAL MORTALITY

Structure & Methods

Committee Structure

The aim of the committee structure is to provide transparent management, which is open to all participants through a democratic process. This, along with the methodology, is designed to increase the sense of ownership and acceptance of SASM and its work by those audited. The management structure consists of:-

SASM Board
SASM Management Committee
SASM Liason Group

SASM Board
Members of SASM Board

The SASM Board is responsible for strategic planning and policy and is the top layer of management. It consists of:

The Chairman is a surgeon and the Chairmanship rotates between the two Surgical College Presidents on a 3 yearly basis.

The SASM Management Committee
Members of the Management Committee

The Management Committee is responsible for the administration of the Audit and reports to the SASM Board. The Management Committee consists of:

The Chairman has a 3-year term of office, renewable annually thereafter, up to a further 3 years. The Board, from current members of the Management Committee, appoints him or her. The other clinical members have a fixed 4-year term of office. Co-ordinators self-nominate from present and past 1^st line assessors and are voted for by the participants in the responsible area. From within the co-ordinators a surgical and anaesthetic sub-group chairman is chosen. Additional members of the Management Committee are:

Each clinical member also has an area of individual responsibility within the SASM (i.e. Quality Assurance, Academic Activity, Critical Care, Medico-legal Development, Casenote report books, Orthopaedic Development).

Data collection

Mortuaries, records offices, wards and consultants’ secretaries, are the source of information for recording deaths occurring within thirty days of an operation or during the patient’s last admission. Pro formas are sent to the consultant surgeon in charge of the case. The surgeon is asked to identify the anaesthetist involved, where relevant, and to pass on the anaesthetic pro forma and the case notes. Both surgeon and anaesthetist return the completed pro formas to the SASM office in pre-addressed envelopes.

All identifiers are removed from the pro formas before they are sent to a 1^st line surgical assessor from an appropriate specialty and, in the case of operative cases, to an anaesthetic assessor.

• All consultants participating in the audit are contacted and asked if they wish to act as first line assessors. A wide geographical distribution of 1^st line assessors protects anonymity within SASM.
• Each 1^st line assessor assesses approximately 60 cases a year.
• One third of each group will retire each year to allow continual movement but at the same time retain a degree of continuity.
• 1 in 10 of assessments with no adverse events are reviewed by the coordinators in each office to allow for internal audit.
• All cases with an adverse event are reviewed by the coordinators to allow for internal audit.
• Twice a year there will be a meeting of all assessors to discuss problems, ways to improve assessments, and changes to the following year’s audit forms.

Structured 1^st line and case note review forms are used. (If a change is made to the assessment either due to further information from the clinician or as a result of the review process a coordinator form is completed.)

The interim analysis is returned to the clinician and a response invited. If no response is returned a final unchanged review is recorded. If further information or opinion is returned by the clinician this is appended to the review document and recorded. In cases where an "area of concern" contributed to or caused death and the clinician disputes the opinion, the clinician is asked to supply the name of at least 4 clinicians outwith their area whose opinion the clinician would accept. One of these is then approached with a guarantee of anonymity to conduct a final case review. Once performed this is again fed back to the clinician and a response invited which is added to the final review and the result recorded.

If assessors consider that there is insufficient information in the pro formas to come to any conclusions about the case, or if they feel that there are factors that warrant further information, then they have the option to request a case note review. The clinical co-ordinator reviews the request and if supported, the notes and forms are sent to a case note reviewer in the relevant specialty. The case note reviewer is asked to provide a summary of the case and of his/her findings and to complete an assessor’s form. The case note reviewers are derived from virtually all participating clinicians.

Areas of concern or for consideration

When cases are reviewed, by either first line assessors or at case note review, events or factors that are thought to be sub-optimal and should have been improved, have been recorded as "areas of concern". These encompass issues that are specific to surgical and anaesthetic care, or may relate to hospital or handling concerns. Areas where there is debate, but the assessors feel that an alternative view could have been considered, are termed "areas for consideration".

Guidance for the definition of an area of concern

An area of concern is an unintended "mishap" caused by medical management rather than by disease process, which is sufficiently serious to lead to prolonged hospitalisation or to temporary or permanent impairment or disability of the patient at the time of discharge, or which contributes to or causes death.

• Medical management includes actions of the responsible clinician (surgeon or anaesthetist) or other clinician, the resource available, and the system as a process. Areas of concern brought about by failure of equipment or its provision will also be included.
• Medical management includes acts of omission: for example, failure to diagnose or treat, and commission: for example, incorrect treatment. Injuries that come about from failure to arrest the disease process are also included provided that standard care would clearly have prevented the injury.
• Areas of concern may or may not be preventable. An area of concern is considered preventable if the reviewer judges that it would not have occurred if the patient had received an ordinary standard of medical care appropriate for the time: for example, omission of prophylactic antibiotics or anticoagulants specified in national guidelines.
• Assessment of preventability will be divided into two: on balance unpreventable, and on balance preventable.
• Areas of concern will also be judged on their impact with respect to death, either none, low, moderate or high.

These will be allocated to specific areas of care.

• Clinical – i.e. related to the clinical care within the control of the audited clinicians
• Resource – e.g. theatre or HDU/ITU availability
• Other – i.e. issues outwith the control of the audited clinicians not related to resource

In addition form completion, inconsistencies and inaccuracies are also recorded under an "S" code.

The basis of an opinion must also be given (e.g. randomised control trial, SIGN guideline, personal opinion). This should result in a focussed assessment with graduated critical comment.

In addition the assessor is asked to indicate whether the issue was declared by the audited clinician, whether it was preventable and its degree of impact on the outcome.

Data entry

The diagnoses and operations are recorded using Read codes. Any areas of concern or consideration in management noted by the assessors are coded using locally devised codes, structured along the same lines as Read codes.

Participants’ feedback

Each case with an area of concern or for consideration and following a case note review is fed back to the participant as the audit process outlined above is completed. In 2006 all participants will also receive an annual review comprising all the cases for a calendar year.

Trust Feedback

Trusts receive analysis of the data, providing a summary of their data along with a comparison against the total for the rest of the country.

Case report book

Anonymised collated case reports are circulated to surgical and anaesthetic consultants and trainees at intervals.

How to do a Case Note Review
PowerPoint Presentation (593kb)