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Quality management

ChiBASE

The Department of Visceral, Transplant, and Thoracic Surgery has, in addition to the Clinical Information System (CIS), a proprietary, quality-assured, and audit-capable documentation system. This quality-controlled registry meets all criteria of a “registry‑embedded clinical trial” and therefore represents a unique tool for quality assurance and health services research. Furthermore, it constitutes a mandatory foundation for all translational research.

The participation of all patients in studies at a university hospital is a vision that, for various reasons, has not yet been realized. The concept of “registry‑embedded clinical trials” meets, on the one hand, all requirements for verifiable, high‑quality medical data at the highest level (auditability), and on the other hand allows, for the first time, retrospective analyses to be equated with the quality level of randomized clinical trials (RCTs) by using appropriate statistical methods (propensity score analysis). This revolutionary concept is represented in certain areas by the National Surgical Quality Improvement Program (NSQIP®) of the American College of Surgeons (ACS) and by individual national and international registries, but it has never been implemented in daily clinical routine at a hospital, except at the Department of Surgery of the Paracelsus Medical University (PMU) Salzburg. One of the major obstacles until now has been the lack of clinically oriented documentation systems, the increased time required for documentation, and the inability to develop a general prototype suitable for multiple surgical departments.

ChiBASE meets the first two requirements mentioned above and has already been tested in daily clinical practice. It is not only a tool for assessing outcome quality—and thus an essential instrument for quality management as well as for clinical and translational research—but it also maps the equally important process quality of clinical workflows. From a technical standpoint, it is not tied to any specific software front‑end. Its key and indispensable features for success are, on the one hand, the jargon catalogues (e.g., ICPM++ and ICD‑10++) and, on the other hand, the principle that data are collected at the point where they are generated—this also includes mobile data entry using tablets. Ultimately, these data are reviewed across several levels that are established in daily clinical routine. In addition, data analysis—both through predefined routines and through data export into statistical software—must be possible across all available data, independent of time and personnel, meaning without requiring assistance from third parties. Coding (centered on the jargon catalogues) and, where appropriate, stratification of the data are performed. Taken together, this results not only in excellent data quality for scientific purposes but also in a knowledge database that is essential not only for the medical leadership of a university hospital but also, through the inclusion of economic parameters, for hospital administration.

M&MC

(Morbidity and Mortality Conferences)
Regular and structured discussions of all deaths and complications at the Department of Visceral, Transplant, and Thoracic Surgery are an integral part of routine quality assurance. The responsible staff at the department have extensive experience in this area and have received international recognition (D. Öfner: Multidisziplinäre Tumorboardkonferenzen im Patientensicherheitsmanagement; Gausmann P (ed.) de Gruyter Verlag 2015)

MDT

(Multidisciplinary Tumor Boards)
The Department of Surgery I of the university hospital (the predecessor of the Department of Visceral, Transplant, and Thoracic Surgery) was a pioneer in this field in collaboration with the Department of Radiation Therapy and Oncology, when in 1993 the first of these modern MDTs in Austria was institutionalized. Prof. Lukas (Director of the Department of Radiation Therapy and Oncology) and the then attending surgeon Dr. D. Öfner held the first conferences. Today, the MDT has become indispensable in daily clinical practice and is being further developed under the leadership of Prof. Öfner in the form of intradisciplinary tumor boards together with surgical partners in North, East, and South Tyrol, as well as in Vorarlberg.

Quality assurance routines

Daily routine

  • Morning briefing: near‑miss events and pitfalls in loop view; review of the day’s OR schedule; journal club and knowledge database; creation and archiving of SOPs; use of the “digital whiteboard”; overview of quality assurance (daily presentation of key clinical indicators and tracer diagnoses and complications); review of procedure coding (including OR times and surgeons), ad‑hoc correction, stratification (emergency – early elective – elective, reoperation, unplanned – planned); review of coding of intraoperative complications; handover based on a table of admissions with stratification (acute – planned, readmission within 14 days, transfer from other hospitals, reason for transfer, clinical progression); discussion and stratification of deaths (mors in tabula – postoperative (ICU, recovery room, ICU, observation unit, ward) – after conservative treatment, inpatient – outpatient; unexpected – expected); radiology review of acute on‑call X‑rays, clinical progression.
  • Indication and radiology review: OR schedule for the next day, discussion of surgical indications; radiologic images from the day and for patients scheduled for surgery, clinical progression.
  • Further daily routines: ward work (complications, infections, clinical progression); admission documentation (admission diagnosis, type of admission).
  • Admission and discharge documentation (A3‑format discharge documentation, classification into primary and secondary procedures and diagnoses, copy of the temperature chart, Charlson comorbidity index); cross‑check of OR documentation, OR scheduling.

Weekly routines

  • Tumor board meetings: stratification, clinical progression.
  • Chief ward round: coding of complications, clinical progression of orders.
  • List of oncological cases with stratification (not relevant for tumor board discussion, with reason [discussed – not multimodal] – on recent list – next time – for which tumor conference)

Monthly routines

  • M&MC: slides in the system, stratification, knowledge database, clinical progression.
  • Link to the Tyrol tumor registry with transmission of the current data

Yearly routines

  • Annual report: reporting on services
  • Retreat (twice a year): strategic considerations, measures to increase efficiency