Document ID: chunk:federal_register_of_legislation:F2021L00470:schedule:1
Version: federal_register_of_legislation:F2021L00470
Segment Type: schedule
Provision Reference: sch 1
Character Range: 2331–5145

Schedule 1— Description of quality assurance activity

1 Name of activity:

    Top End Health Service Peer Review Clinical Audits of Surgical Mortalities and Morbidities

2 Description of activity:

    This declaration applies to the Top End Health Service (TEHS) Peer Review Clinical Audits of Surgical Mortalities and Morbidities (the Activity). The Activity involves clinical reviews and analysis of patient cases that result in death, or where the patient incurred complications or substantial or long-lasting disability after discharge. The reviews and analysis involve specialist surgeons, anaesthetists and other clinicians who perform surgical operations and who provide care for patients at the Top End Health Service, including patients admitted under the surgical team but who did not proceed to have an operation. The Activity identifies contributing clinical factors to these events and makes recommendations to the Executive Director Medical Service of the TEHS about changes or improvements in a policy, procedure or practice relating to the provision of health services to reduce the likelihood, or prevent the same or similar event from occurring again. The Activity includes the monitoring of those recommendations.

    The Activity also includes reviewing and analysing operational policies, procedures or practices and clinical issues and factors that contribute to the occurrence of an event. Dependent on the circumstances of the event, the clinical practice and performance of individuals may also be discussed.

    Clinical audit reports and recommendations approved by the Executive Director of Surgery TEHS are provided to the Chief Operating Officer and Executive Director, Medical Services TEHS and circulated within the hospital. Publication of non‑identifying information will occur through the NT Health Annual Report, NT Health Clinical Quality and Patient Safety Surveillance Report and NT Audit of Surgical Mortality. The following specific information will be published arising from the Activity:
          (i)      number of cases reviewed;
          (ii)      audit of attendance numbers at the TEHS Activity;
          (iii)      percentage of eligible cases audited;
          (iv)      a summary of themes that contribute to morbidity and mortality;
          (v)      high level details of particular cases;
          (vi)      recommendations made to improve policies, practices and procedures; and
          (vii)      a description of issues raised during M&M meetings that arise from assessing safety and quality systems and M&M meetings at the TEHS.

    Access to identifying information is limited to clinician peers conducting the audit activity and the Executive Director of Medical Services, Chief Operating Officer and NT Department of Health Legal Services.