RoyalAustralasianCollege of Surgeons

Manual:
Division:
Subject: / Policies and Procedures –General
Research and Audit Division
Disclosure of information from national breast cancer audit policy / Ref. No.:
Approval Date:
Review Date:
Revision No.:
Page: / 05/02/2007
"[revision date]"
0
1 of 3

1.PURPOSE AND SCOpe

This policy defines the process for dealing with requests for access to National Breast Cancer Audit (NBCA) data.

2.KEY DIRECTION STATEMENT

The National Breast Cancer Audit is run under the direction of the Royal Australasian College of Surgeons (RACS). The RACS is committed to ensuring the highest standard of safe and comprehensive surgical care for the community they serve through excellence in surgical education, training, professional development and support.

The NBCA aims to improve the surgical care and management for all people with early breast cancer in Australia and New Zealand through the careful collection and analysis of audit data and the application of a full cycle of clinical audit. Clinical audit can be defined as:

  • measurement of individual surgeon data against minimum standards
  • the application of an outlier process to monitor and provide feedback on individual performance
  • provision of aggregated data to hospitals and governments to improve quality of services provided

It also aims to keep up to date with changes in treatment based on available evidence and ensure wide dissemination of this information to practitioners.

3.VALUES

  • Service and Professionalism
  • performing to and upholding the highest standards
  • Integrity
  • upholding professional values
  • Respect and Compassion
  • being sympathetic and empathetic
  • Commitment and Diligence
  • being dedicated, doing one’s best to deliver
  • Collaboration and Teamwork
  • working together to achieve the best outcome

4.BACKGROUND

The NBCA collects data from surgeons regarding the treatment of patients with early breast cancer in Australia and New Zealand. Over 10,000 patients are treated annually for breast cancer, a large proportion of these being for early breast cancer. The audit is attempting to collect as many cases of early breast cancer as is practicable on an ongoing basis. The collection of data comprises a significant bi-national information resource describing the treatment of these patients.

This policy is intended to define a clear procedure for dealing with requests for data and/or information from the audit. Requests vary from the straightforward to highly complex and can originate from a variety of sources. The one thing all requests have in common is their need to use, in some capacity, data collected by the audit.

Information entered into the audit by surgeons does not identify the patients. In addition the audit has Qualified Privilege, which prohibits the disclosure of any information that could identify an individual beyond the agreed parameters of the activity. This policy therefore does not apply to any enquiries that require access to individual surgeon’s data or to any such data that might identify a particular surgeon or surgeons unless requested by a group of surgeons who consent to their group having access to this information?

Ownership of data: surgeons have ownership of their own data. The data collection in its entirety is owned by the RACS.

The value of research based on audit data is recognised and will be encouraged.

Requests for data may arise from the following sources:

  • Public enquiries regarding audit data
  • Commercial entities (eg. pharmaceutical companies)
  • Non-governmental organisations (eg. universities)
  • Hospitals
  • Federal Government
  • State Governments
  • Media requests
  • Breast Section
  • Fellows
  • Trainees and students

5.BODY OF POLICY

The policy is categorised under the following headings:

5.1 Logging requests for data

5.2 Composition of audit subcommittee

5.3 Role of audit subcommittee

5.4 Charging for data requests

5.5 Ethics and privacy

5.1 Logging requests for data

Requests for data should be directed to the NBCA staff. The staff member should ask the requester to complete the submission for data requests form. The form requests the contact details of the person requesting data, organisation or other source requiring information, what information is required and for what purpose, and a time by which the information is needed.

The audit staff should then:

1. Estimate how much time would be needed to provide the data; and

2. Document whether the person or organisation will accept data extracted directly from the audit, or whether the data will have to be processed for the enquirer.

Once this information has been compiled, it can be submitted to a Data Request Subcommittee comprising the Chair of the Breast Section and the Chair of ACAC for consideration. Decisions from this subcommittee will be forwarded to members of the Steering Committee for ratification.

Helping individual surgeons extract their own information from the audit should be undertaken by the audit staff. However, if a surgeon requires further processing of data then this request should be referred on to the committee.

5.2 Composition of data request subcommittee

A data request subcommittee should be convened comprising the Chair of the Breast Section, the Chair of the Audit Clinical Advisory Committee and a surgeon representative from New Zealand. Ratification for any decision will be sought from the Steering Committee convened by the funding body. Neither the Data Request Subcommittee nor the Steering Committee need to meet in person or via teleconference, to consider individual requests, if these can be dealt with using other forms of communication (i.e. email).

5.3 Role of audit subcommittee

The Data Request Subcommittee will be asked to review each request for audit data provided to them by the audit staff. Where additional information is required, the subcommittee can request that this be provided. The subcommittee should review the request and consider any possible negative political, financial, workforce or other impact. The request should be processed by the subcommittee in a timely fashion (within two weeks of the request being submitted). Decisions made by this subcommittee require ratification by the Steering Committee. Once a final decision has been made, one member of the Data Request Subcommittee should be delegated to correspond either directly with the applicant or indirectly through the audit staff. The response should be in written form to facilitate the keeping of records.

5.4 Participation of audit staff

The Data Request Subcommittee may decide that the release of data can only be approved on the condition of suitable participation of audit staff in the process of data analysis and report preparation. In all cases, the final report based on audit data needs to be approved by the Data Request Subcommittee and the Steering Committee.

5.5 Charging for data requests

The Data Request Subcommittee may decide that a request for data can be approved, but that some financial contribution must be made. Estimates for charging should be based on an hourly rate derived from the hourly charge-out rate of the staff member/s involved.

5.6 Ethics and privacy

Requests for unit record data can only be granted to the respective provider. Other external requests for unit record data cannot be permitted as this would breech the terms of the Qualified Privilege.

6.PROCEDURES

Approver“[Director or EGM]”

Authoriser“[Council]”