Standards reporting guide - Ensuring correct patient, site, side and procedure [CCC]
To provide the HQCC with an indication of the degree to which your hospital is complying with this standard, we have developed reporting requirements. These are made up of a set of measures with related data items.
A brief description of the measures, including their rationale and interpretation notes is presented below. Each measure is derived from one or more data items. The data items are the questions or specific pieces of information that are required to be reported to the HQCC. The data items are described below the Measures section.
All data items relate to the reporting period, unless otherwise specified.
Measures
Number of invasive procedures involving an incorrect patient, site, side or procedure incident resulting in a Serious or Major consequence (CCC_M1)
| Rationale: |
Measure of outcome. |
| Interpretation: |
Nil expected. |
| Data items: |
CCC_D1 |
Number of invasive procedures involving incorrect patient, site, side or procedure incident resulting in a Moderate consequence (CCC_M2)
| Rationale: |
Measure of outcome. |
| Interpretation: |
Low number expected. |
| Data items: |
CCC_D2 |
Number of invasive procedures involving incorrect patient, site, side or procedure incident resulting in a Minor or Minimal consequence (CCC_M3)
| Rationale: |
Measure of reporting culture. |
| Interpretation: |
High number expected. Dependant on extent of reporting of incidents. |
| Data items: |
CCC_D3 |
Proportion of surgical procedures where the Surgical safety checklist was completed (CCC_M4)
| Rationale: |
Measure of process. |
| Interpretation: |
100% expected by 30 June 2011. May be based on the full population or a sample audit. |
| Data items: |
CCC_D6, CCC_D5 |
Can you demonstrate that your hospital follows a process for ensuring correct procedure that includes all the criteria of the HQCC Ensuring Correct Patient, Site, Side and Procedure standard? (CCC_M5)
| Rationale: |
Demonstrates existence and alignment of process. |
| Interpretation: |
Yes expected. |
| Data items: |
CCC_D7 |
Can you demonstrate that your hospital has analysed data related to ensuring correct patient, site, side and procedure to identify risks to patient safety and opportunities for quality improvement? (CCC_M6)
| Rationale: |
Demonstrates analysis of relevant data to identify risks to patient safety and opportunities for quality improvement. |
| Interpretation: |
Yes expected. |
| Data items: |
CCC_D8 |
Can you demonstrate that your hospital has implemented quality improvement activities related to ensuring correct patient, site, side and procedure? (CCC_M7)
| Rationale: |
Demonstrates quality improvement. |
| Interpretation: |
Yes expected. |
| Data items: |
CCC_D9 |
Data items
The data items are the questions or specific pieces of information that are required to be reported to the HQCC. These are listed below with a brief technical description. The HQCC will calculate the measures (listed above) based on the data items provided. Underlined terms are defined in the
glossary.
Ideally, the HQCC prefer the data reported to be based on the full population (i.e. all patients). We understand that without integrated electronic systems to routinely capture key information as a by-product of work processes this may be impractical for many providers and may not reflect the most efficient use of your hospital’s resources. If you can not report data for the full population for data items CCC_D5 and CCC_D6, the HQCC will accept data based on a sample (however, the full population is required for data items CCC_D1, CCC_D2, CCC_D3, and CCC_D4). Further information on sample audits is provided for each relevant data item below and in the sample audit guidelines (see Sample size for audits and Sampling methodology for audits above).
Number of invasive procedures involving an incorrect patient, site, side or procedure incident resulting in a serious or major consequence (CCC_D1)
Count the total number of invasive procedures with an incident of incorrect patient, site, side or procedure of procedures resulting in a serious or major consequence, such as death or permanent harm or reduction in functioning.
For private hospitals, use the Consequence category, not the Risk category.
For Queensland Health, this maps to SAC1.
The definition of invasive procedures includes all procedures involving the insertion of an instrument, appliance or other object into human tissue, organs, body cavities or body orifices.
Examples include:
- surgical procedures performed in operating theatres
- procedures performed in:
- radiology (e.g. general radiology and ultrasound, interventional radiology, CT and MRI)
- mental health (e.g. electroconvulsive therapy)
- nuclear medicine, radiation therapy and oral health
- procedures such as subcutaneous and intramuscular injections, blood collection, suturing of superficial wounds and examinations of the mouth.
The full population is required for this data item - a sample audit is not acceptable.
Type: Number
Number of invasive procedures involving an incorrect patient, site, side or procedure incident resulting in a moderate consequence (CCC_D2)
Count the total number of invasive procedures with an incident of incorrect patient, site, side or procedure of procedures resulting in a moderate consequence, such as temporary harm or reduction in functioning.
For private hospitals, use the Consequence category, not the Risk category.
For Queensland Health, this maps to SAC2.
The definition of invasive procedures includes all procedures involving the insertion of an instrument, appliance or other object into human tissue, organs, body cavities or body orifices.
Examples include:
- surgical procedures performed in operating theatres
- procedures performed in:
- radiology (e.g. general radiology and ultrasound, interventional radiology, CT and MRI)
- mental health (e.g. electroconvulsive therapy)
- nuclear medicine, radiation therapy and oral health
• procedures such as subcutaneous and intramuscular injections, blood collection, suturing of superficial wounds and examinations of the mouth.
The full population is required for this data item - a sample audit is not acceptable.
Type: Number
Number of invasive procedures involving incorrect patient, site, side or procedure incident resulting in a minor or minimal consequence (CCC_D3)
Count the total number of invasive procedures with an incident of incorrect patient, site, side or procedure of procedures resulting in a minor or minimal consequence, such as an increased level of care, additional investigations or referral to another clinician or an incident with no injury.
For private hospitals, use the Consequence category, not the Risk category.
For Queensland Health, this maps to SAC3.
The definition of invasive procedures includes all procedures involving the insertion of an instrument, appliance or other object into human tissue, organs, body cavities or body orifices.
Examples include:
- surgical procedures performed in operating theatres
- procedures performed in:
- radiology (e.g. general radiology and ultrasound, interventional radiology, CT and MRI)
- mental health (e.g. electroconvulsive therapy)
- nuclear medicine, radiation therapy and oral health
- procedures such as subcutaneous and intramuscular injections, blood collection, suturing of superficial wounds and examinations of the mouth.
The full population is required for this data item - a sample audit is not acceptable.
Type: Number
Total number of principal surgical procedures (CCC_D4)
This is the same number reported as SSA_D4.
Full population size of principal surgical procedures.
The definition of principal surgical procedures includes procedures that are surgical in nature, carry a procedural risk and are performed for diagnosis/investigation/treatment of the principal diagnosis. Procedures which are non-surgical in nature such as anaesthetic or other additional procedures, should not be counted.
In counting the total number of principal surgical procedures, include principal surgical procedures conducted on:
- admitted adult patients who underwent a surgical procedure
- obstetric patients who underwent a surgical procedure
- day procedure patients who are admitted.
Exclude principal surgical procedures conducted on non-admitted patients.
Please note that the number of principal surgical procedures in the reporting period may be different from number of surgical patients in the reporting period if a patient had more than one surgical procedure in the reporting period.
The full population is required for this data item - a sample audit is not acceptable.
If a sample audit is used for other data items in this standard, this number can be used to determine the effectiveness of the sample size.
Type: Number
Number of principal surgical procedures in the audit (CCC_D5)
If you can report CCC_D6 based on the full population, do so and report the population size (CCC_D4) as the size of this audit (CCC_D5).
If you are unable to report on the full population, audit a sample of principal surgical procedures (see description for CCC_D4). See sample audit guidelines for advice on recommended sample size and methodology (see Sample size for audits and Sampling methodology for audits above).
Count the number of principal surgical procedures in the audit.
The definition of principal surgical procedures includes procedures that are surgical in nature, carry a procedural risk and are performed for diagnosis/investigation/treatment of the principal diagnosis. Procedures which are non-surgical in nature such as anaesthetic or other additional procedures, should not be counted.
The same sample could be used for SSA_D4.
Type: Number
Number of principal surgical procedures where a surgical safety checklist was completed (CCC_D6)
Based on the audit of surgical patients, see CCC_D5.
Count the number of principal surgical procedures in the audit where a surgical safety checklist was completed.
Type: Number
Can you demonstrate that your hospital follows a process for ensuring correct surgery that includes all the criteria of the HQCC Ensuring correct patient, site, side and procedure standard? (CCC_D7)
Answer Yes or No only. The hospital’s process must include all criteria of the HQCC standard. The HQCC may request further information about alignment with the standard.
Type: Yes/no
Can you demonstrate that your hospital has analysed data related to ensuring correct patient, site, side and procedure to identify risks to patient safety and opportunities for quality improvement? (CCC_D8)
Answer Yes or No. The HQCC may request further information about the analysis.
The analysis may take the form of looking at performance trends across time, reviewing performance against benchmarks or peers, looking for subgroups within your hospital (such as wards or clinicians) with better or worse performance, looking for subgroups of patients with better or worse outcomes.
The analysis could look at:
- outcome data, consequences of the incident, such as death or likely permanent harm, temporary harm or minimal or no harm
- process data, such as completion of patient identification checks, matching of patient details with the procedure request form/consent form, site/side verification and marking, final check immediately prior to the procedure, reviewing clinical incidents or complaints related to procedures
- evaluating the impact and effectiveness of related quality improvement initiatives.
Type: Yes/no
Can you demonstrate that your hospital has implemented quality improvement activities related to ensuring correct patient, site, side and procedure? (CCC_D9)
Answer Yes or No. The HQCC may request further information about the quality improvement activity.
Type: Yes/no
Potential data sources
- Surgical Safety Checklist Australia & New Zealand Edition
- Clinical incident reporting system (e.g. PRIME, RiskMonitorPro, RiskMan)
- Operating room management information system (ORMIS, HBCIS-TMS)
- ICD-10-AM codes to detect readmission in coding system (HBCIS, other)
- Pre-operative checklist
- Anaesthetic record
- Transition II
- Patient chart
- Laboratory report
- Pharmacy dispensing record
- Hospital coding report
- Administrative data (e.g. admitted patient indicators)