{"id":"F2021L00470","name":"Health Insurance (Quality Assurance Activity – Top End Health Service Peer Review Clinical Audits of Surgical Mortalities and Morbidities) Declaration 2021","slug":"health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":101707,"registerId":"commonwealth-F2021L00470-current","compilationNumber":null,"startDate":"2026-04-03","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n This instrument is the Health Insurance (Quality Assurance Activity – Top End Health Service Peer Review Clinical Audits of Surgical Mortalities and Morbidities) Declaration 2021.","sortOrder":0},{"sectionNumber":"2","sectionType":"section","heading":"Commencement","content":"#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1. The whole of this instrument

The day after this instrument is registered.

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.","sortOrder":1},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This declaration is made under subsection 124X(1) of the Health Insurance Act 1973.","sortOrder":2},{"sectionNumber":"4","sectionType":"section","heading":"Repeal","content":"#### 4 Repeal\n\nThis instrument is repealed when it ceases to be in force in accordance with subsection 124X(4) of the Health Insurance Act 1973.","sortOrder":3},{"sectionNumber":"5","sectionType":"section","heading":"Schedule","content":"#### 5 Schedule\n\n The quality assurance activity described in the Schedule to this Declaration is, to the extent that the quality assurance activity relates to health services provided in Australia, declared to be a quality assurance activity to which Part VC of the Health Insurance Act 1973 applies.\n\n \n\nSchedule 1— Description of quality assurance activity\n\n1 Name of activity: \n\nTop End Health Service Peer Review Clinical Audits of Surgical Mortalities and Morbidities\n\n2 Description of activity:\n\nThis 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.\n\nThe 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.\n\nClinical 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:\n\n (i) number of cases reviewed;\n (ii) audit of attendance numbers at the TEHS Activity;\n (iii) percentage of eligible cases audited;\n (iv) a summary of themes that contribute to morbidity and mortality;\n (v) high level details of particular cases;\n (vi) recommendations made to improve policies, practices and procedures; and\n (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.\n\nAccess 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.","sortOrder":4}],"analysis":{"kimi_summary":{"content_quality":"ok","complexity_score":2,"scope_assessment":{"changed":false,"description":"This is a standard, narrow declaration under the Health Insurance Act 1973. It serves exactly its intended purpose: to confer privilege protection on a specific quality assurance activity (surgical mortality and morbidity audits at Top End Health Service). There is no scope creep — the instrument precisely matches the original legislative intent of allowing confidential clinical peer review."},"complexity_factors":["Very short instrument (approximately 1.5 pages of substantive content)","Only 5 formal sections plus a Schedule","No defined terms section — terms used in plain English","Single cross-reference to the enabling legislation (Health Insurance Act 1973, subsection 124X(1))","Automatic repeal mechanism (self-terminating under subsection 124X(4))","Straightforward declaratory structure: 'The activity described... is declared to be...'","No conditional logic, exceptions, or nested provisions"],"plain_english_summary":"This law gives legal privilege to Top End Health Service’s Morbidity & Mortality (M&M) surgical review meetings under Part VC of the Health Insurance Act, protecting confidential case discussions from being used in court. \n\nBy shielding surgeons, anaesthetists and review teams, it promotes frank analysis of deaths and serious complications, allows anonymised reporting of themes, and aims to improve hospital practices and patient safety."},"flash_summary_failed":{"failed":true,"reason":"Unauthenticated. Configure AI_GATEWAY_API_KEY or use a provider module. Learn more: https://ai-sdk.dev/unauthenticated-ai-gateway","source":"analysis-cron"},"flash_summary":{"complexity_score":3,"scope_assessment":{"changed":false,"description":"The instrument does not expand or narrow the substantive activities beyond the Schedule: it formally designates the described TEHS peer review clinical audits as a Part VC \"quality assurance activity\" and sets out participants, data access limits, reporting and publication rules. It does not add procedural powers, funding arrangements or additional categories of activity beyond the Schedule description."},"complexity_factors":["Legal hook to the Health Insurance Act 1973 (authority under subsection 124X(1)) — links the declaration to Part VC protections and procedures (section 3).","Repeal tied to statutory condition (ceases in force under subsection 124X(4)) — creates an external end point rather than an explicit expiry date in this instrument (section 4).","Detailed operational description in the Schedule — defines covered events, participants, outputs and monitoring responsibilities (Schedule, items 1–2).","Confidentiality and limited access to identifying information — access limited to clinician peers, Executive Director Medical Services, Chief Operating Officer and NT Health Legal Services, which concentrates information control and creates compliance requirements for record handling (Schedule, final paragraph).","Reporting, approval and circulation chain — clinical audit reports require approval by the Executive Director of Surgery TEHS and are provided to named executives and circulated within the hospital, creating administrative obligations on TEHS staff (Schedule, paragraph on reports and recipients).","Publication of non‑identifying aggregate metrics and themes — specifies what may be published (number of cases reviewed, percent audited, themes, high‑level case details, recommendations), requiring data aggregation and redaction processes (Schedule, published information list (i)–(vii)).","Potential review of individual clinician performance — instrument permits discussion of clinical practice and individual performance depending on circumstances, which raises procedural and privacy considerations for those persons (Schedule, paragraph on discussion of clinical practice).","Commencement mechanics are simple but binding — instrument commences the day after registration, so implementation timing is immediate (section 2(1)).","No funding, enforcement or resourcing measures included — the instrument is silent on who pays for audits or implementation of recommendations, leaving operational burden to TEHS and NT Health (silence in Schedule)."],"plain_english_summary":"Declares the Top End Health Service Peer Review Clinical Audits of Surgical Mortalities and Morbidities to be a \"quality assurance activity\" under Part VC of the Health Insurance Act 1973, covering reviews of deaths, complications and significant post‑discharge disability related to surgical care in Australia. The instrument limits access to identifying data to participating clinician peers and named NT Health officers, requires reports and recommendations to TEHS executives, and allows publication of non‑identifying aggregate findings."}},"importantCases":[],"_links":{"self":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su","history":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su/history","analysis":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su/analysis","conflicts":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su/conflicts","importantCases":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su/important-cases","documents":"/api/acts/health-insurance-quality-assurance-activity-top-end-health-service-peer-review-clinical-audits-of-su/documents"}}