RNSH SURGICAL EDUCATION RESEARCH AND TRAINING (SERT) INSTITUTE 2024 OPERATIONAL REPORT
SURGICAL EDUCATION RESEARCH & TRAINING (SERT) INSTITUTE ROYAL NORTH SHORE HOSPITAL
Northern Sydney Local Health District Royal North Shore Hospital Reserve Road St Leonards NSW 2065
E: NSLHD-RNSH-SERTInstitute@health.nsw.gov.au
This work is copyrighted. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the SERT Institute at Royal North Shore Hospital.
Published May 2025
RNSH SERT INSTITUTE OPERATIONAL PLAN REPORT
Table of Contents
1
SERT Reporting Timeline
2 4
Introduction
Executive Summary
7
Progress Tracker 2024
9 12 15 18 21 24
Key Priority Area 1 : Operations & Business
Key Priority Area 2 : Promotion & Engagement
Key Priority Area 3 : Research
Key Priority Area 4: Education & Training
Key Priority Area 5: Innovation & Quality Improvement
Key Priority Area 6: Data & Audit
SERT Institute Reporting and Meeting Timeline
Operational Report Jan-Jun 2024 published SERT Advisory Committee Meeting
JUL 2024
8,603 NOV 2024
SERT Advisory Committee Meeting
DEC 2024
Surgeons Social Event
Surgical Awards Night
FEB 2025
Research Activity Report 2023-24 published Surgeon Leadership 2025 Session 1 Operational Report 2024 (12 mths) published
MAY 2025
Surgeon Leadership Session 2
JUNE 2025
SERT Advisory Committee Surgeon Leadership Session 3
JUL 2025
AUG 2025
Surgeons Social Event
Surgeon Leadership Session 4
OCT 2025
SERT Advisory Committee
NOV 2025
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Introduction
The Royal North Shore SERT Institute 2024 Operational Report, provides a structured framework for tracking progress against the Surgical Education Research and Training Institute's strategic plan from 2023-2027. All six key priority areas identified in the plan align to the Northern Sydney Local Health District's commitment to patient-centered care, enhance accountability and promote continuous quality improvement in surgical education, research and training The SERT Institute Advisory Committee established in April 2024, provides guidance, monitors progress and achievements of the planned objectives, ensuring that initiatives are delivered and coordinated effectively by both the SERT Institute and the Data Analysis Surgical Outcome (DASO) Unit.
This report was proudly produced by the RNSH SERT Institute Team. Wide distribution of this document is encouraged.
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The SERT Institute Vision and Purpose
The SERT Institute six key priority areas covered in this report
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Executive Summary
The Royal North Shore Hospital (RNSH) Surgical Education Research and Training (SERT) Institute was established to promote, assist and encourage surgeon engagement in academic and quality improvement activities that contribute to improved clinical care and patient outcomes. In December 2023, the SERT Institute's strategic plan 2023-2027 was launched identifying six key priority areas. These were developed through broad consultation with key stakeholders and are aligned to the NSLHD strategic plan 2022-2027, the Clinical Governance Plan, Research Strategy, Digital Strategy and Precinct Plan 2022. The SERT Institute Advisory Committee established in April 2024, provides guidance, monitors progress and achievements of the planned objectives, ensuring that initiatives are delivered and coordinated effectively by both the SERT Institute and the Data Analysis Surgical Outcome (DASO) Unit.
This 12 month report provides an overview of the SERT Institute progress against the six key priority areas over 2024.
Significant Achievements
Priority Area 1: Operations & Business
The SERT Institute Advisory Committee was established in April 2024. Sponsored by the NSLHD Chief Executive, membership includes board representatives, senior surgeons, key stakeholders, clinical and research academics. This expert committee aims to provide leadership, strategic guidance, oversight of activities and initiatives of the Institute. It encourages broad stakeholder engagement, consultation and a platform to recognise surgical, research and educational achievements. Business: Over the past 12 months, the SERT Institute operated within budget and recruitment against vacancies were promptly facilitated to support continuity of workflows and activity. A six month report against the strategic direction and operational plan was presented and endorsed by the Advisory Committee in August 2024.
Priority Area 2: Promotions & Engagement
New Website: In 2024, the SERT Institute focused on raising the profile of the institute and surgical initiatives across RNSH. The website was redesigned and transitioned to a new platform in December 2024. It aims to showcase achievements, highlight education, training and research initiatives, significant publications, conferences, awards, innovation, and quality improvement projects. Multimedia and all surgical departments were consulted on the development of standardised profiles and information hosted on this site including an intranet link page that automatically redirect to this website. The SERT Institute website is public facing to connect with the broader community and showcase RNSH surgical services. Data Network Meeting: The RNSH Data Network was launched by the institute in 2024 with the aim of uniting individuals and teams from various departments across RNSH working with data. Three to four meetings per year are planned to encourage knowledge sharing, foster collaborative problem-solving, and provide support and guidance on new technologies. Members include the Performance and Analytics Unit, Intensive Care Unit (ICU), Emergency Department, Medical Oncology, Bone Marrow Transplant, Radiation Oncology, Medical Imaging, and Renal departments.
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Executive Summary Continued
Priority Area 3: Research RNSH Division of Surgery and Anaesthesia Research Activity Report: The inaugural research activity report published in 2021, showcased publications authored by RNSH surgeons over three years from 2018-2020. Following widespread recognition and interest generated from this report the next iteration published in 2023 showcased publications across all DoSA departments from 2021-2022, including Anaesthesia, Intensive Care Unit, the Trauma Service, Allergy Clinic and Acute Pain Management. The RNSH Research Activity Report 2023-2024: This is an equally impressive series of work that continues to highlight the volume of research activity and peer-reviewed publications across the RNSH DoSA in 2023 and 2024. Surgeon Survey: In 2023, the SERT Institute conducted a surgeon survey to identify barriers to academia, research, clinical audit, career advancement and training needs. Issues identified by 66% of surgeons include; work life balance, limited resources to support research and clinical audit, and a lack of awareness regarding pathways to achieving academic titles. The survey findings were presented and discussed at surgical forums, shared with executives and subsequently guided the SERT Institute 2023-2027 plan, in particular the introduction of the RNSH surgical leadership series. Surgeon Engagement: Over 2023 and 2024, surgeons significantly increased engagement with the Data Analysis Surgical Outcome (DASO) Unit, seeking improvement in data collection, development of databases and research support. The DASO Unit also supports surgical departments without a dedicated resource on an “ad hoc” basis to enhance clinical audits, strengthen Morbidity and Mortality (M&M) meetings, improved reporting and validate research data. During 2023-2024, the DASO unit focused on efficiency and accurate reporting through automated data extractions and uploads to national and state registries. The Orthopaedic Spinal Trauma Database also underwent an upgrade during this period and new databases were also developed for the following departments: Breast, Hands, Ophthalmology, Burns and Plastics, and Colorectal services. Priority Area 4: Education & Training Masters of Surgery: In collaboration with the University of Sydney (USYD), the SERT Institute has supported the Masters of Surgery Program on the Northern Sydney Campus by appointing an academic lead. This position provides oversight of the program and manages the clinical skills laboratory (in the Kolling Institute). From 2020, enrollments have significantly increased (currently over 100 per year), and elective subjects have increased from 6 to 20. Surgical Leadership Series: This priority area focuses on strengthening medical education, training, and leadership. After forging strong partnerships with the Western Local Health District (WSLHD) Research Education Network and USYD, a junior consultant leadership program - Fostering Leadership Across Systems in Health (FLASH) was collaboratively developed. In August 2023, the RNSH Surgical Leadership Series for consultants was launched, bringing surgeons together to discuss the expectations, challenges and skills required to foster a positive and supportive surgical culture. The initiative is being designed for surgeons by surgeons through consultation, collaboration, and feedback, ensuring it meets needs and expectations. A total of six sessions have been professionally facilitated by the Pam McLean Centre to explored leadership models, personalities, influences and challenges. In 2025, external guest speakers in surgical leadership roles have been invited to share their journey, experiences and challenges.
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Executive Summary Continued
Priority Area 5: Innovation & Quality Improvement
Dr Ray Hollings Surgical Excellence Award: In May 2023, the SERT Institute hosted the second Dr Ray Hollings Surgical Award in partnership with the RNSH Gastroenterology Department Dr Harry Cumberland Travelling Scholarship Award. Each year, over 80 surgeons and distinguished guests attended. In 2023, three recipients received the Dr Ray Hollings Surgical Excellence Award, aimed at supporting high impact surgical innovation and quality improvement initiatives. The awards were held again in February 2025,and in this year there were two recipients.
Priority Area 6: Data & Audit
Supporting surgical specialties with no data resources: During 2023-24, the DASO Unit supported multiple departments with no dedicated data support by creating customised databases for clinical audits and M&M meetings. For example; the new Colorectal database now allows semi-automated data uploads from SurgiNet and eliminates the need for registrars and fellows to manually enter basic demographic and surgical data. A similar streamlined process was implemented for the Orthopaedic and the Hands department's database, The Hands database was also expanded to include Patient Reported Outcome Measures (PROMs) and the ability to track follow-up clinic attendance and PROMs compliance.
Microsoft Power BI has also been introduced to multiple departments over the past 12months to enhance reporting and further integrate with NSLHD new technologies.
The DASO Unit Data Request Portal was significantly upgraded in 2024 to enable both internal and external stakeholders to submit data requests in addition to tracking additional and out-of-scope requests. The volume of requests received annually remained consistent, with 61 out-of-scope requests received in 2024. Governance processes for releasing and sharing information within and outside of NSLHD are in development ( in consultation with the Performance Unit) and all surgical historical datasets stored in excel spreadsheets have been reviewed and transitioned to new bespoke and more secure databases designed by the DASO Unit.
Progress on each Key Performance Indicator (KPI) is documented and indicated using the colour coding tabs below.
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Progress Tracker for 2024
Key Priority 1 - Operations & Business
1.1. Ensure the direction and future growth of the SERT Institute is aligned to the needs of the District 1.2. Secure infrastructure and resources to support future growth.
1.3. Develop robust reporting against strategic plans.
1.4 Strengthen business acumen and budget performance.
Key Priority 2 - Promotion & Engagement
2.1. Raise the profile of the SERT Institute across RNSH.
2.2. Showcase surgical achievements and improved outcomes.
2.3. Strengthen key partnerships, collaborations, and networks.
2.4. Increase surgeon engagement and participation in non-clinical activities.
2.5 Promote surgical activity and achievements.
Key Priority 3 - Research
3.1. Strengthen surgical departments research capacity.
3.2. Foster and promote a collaborative surgical research culture.
3.3. Enhance internal and external collaborations and partnerships.
3.4. Recognise and promote surgical research achievements and researchers.
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Key Priority 4 - Education & Training
4.1. Deliver and coordinate quality postgraduate surgical education and training. 4.2. Adopt a clear and transparent framework to determine surgical training pathways across the Northern Campus. 4.3. Facilitate clinical leadership development for current and next generation surgeons.
4.4. Establish a high performing team with shared vision and goals.
4.5. Strengthen workforce capacity and skills through training and education.
Key Priority 5 - Innovation & Quality Improvement
5.1. Identify and promote surgical innovation opportunities.
5.2. Support innovation and quality improvement initiatives.
5.3. Promote the utilisation of project management tools and training.
5.4. Strengthen stakeholder connectivity, sustainability and scalability of projects.
Key Priority 6 - Data & Audit
6.1. Develop and improve surgical reporting and embrace new technology. 6.2. Implement strict governance and security measures across surgery data systems and processes. 6.3. Improve engagement and utilisation of available technologies and systems. 6.4. Improve clinician knowledge and understanding of clinical audits and processes. 6.5. Develop and reinforce high standard of data quality for reporting accuracy and research.
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Key Priority Area 1
Operations and Business
1.1 Ensure the direction and future growth of the SERT Institute is aligned to the needs of the District in the context of academic surgery, clinical governance, business acumen and workforce planning The SERT Institute’s vision and direction was guided through broad consultation to develop the initial 3 year SERT strategy 2019-2021 and superseded in 2023, with the development of six key priorities areas and an operational reporting tool spanning 2023-2027, aligned to the NSLHD strategic plan and strategy published in 2023. In April 2024, the SERT Institute Advisory Committee was established, sponsored by the NSLHD Chief Executive. Membership includes board representatives, senior surgeons, key stakeholders, clinical and research academics. This expert committee aims to provide leadership, strategic guidance, oversight of activities and initiatives of the Institute. It promotes broad stakeholder engagement, consultation and a platform to recognise surgical, research and educational achievements. The first official progress report against the SERT Institute Operational Plan 2023-2027 was endorsed by the Advisory Committee in August 2024 and distributed to stakeholders. Feedback received was positive.
Reports will continue to be produced against the operational plan initially at 6months then annually per calendar year until 2027.
Currently, the SERT Institute is on track with all KPI’s and goals. Several KPI’s have been closed off as unachievable or due to a change in organisational priorities.
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1.2 Secure infrastructure and resources to support future growth
DoSA has 14 surgical departments, over 100 surgical consultants and 5 FTE Data Managers supporting 6 sub-specialty services, including Trauma Service. The SERT Institute has continued to work across all surgical specialty services throughout 2023-2024 FY to support quality improvement projects and developed new databases for several unsupported services: Orthopaedics, Colorectal, Hands, Plastics, Perioperative Medicine Service, including the Surgical Outcomes Committee. In November 2023, a GAP analysis was conducted of each surgical department to assess their capacity to support clinical audit, M&M meetings, clinical reporting, research and quality improvement activities. The outcome of the analysis recommended the establishment of three new data manager positions in 2024-2025 FY for the following services: Orthopaedics, Pancreatic and Breast surgery. At the time of publishing this report, only the Orthopaedics application has failed to progress. In late 2019, the SERT Institute was relocated to level 4 of the RNSH Acute Services Building within the Department of Anaesthesia. The current space allows direct access to the operating theatres and interaction with surgeons. The search for a dedicated space for the institute has been exhausted. However, changes in workplace modelling and the introduction of flexible work practices in 2020 has reduced the urgency and need for a dedicated space and the current space meets the Institute requirements. To ensure staff are well supported in the new model and compliant with NSW Health Flexible Working Policy GL2023_020 and local NSLHD safe work environment guidelines, the NSLHD Work Health & Safety (WH&S) workplace assessment checklist is completed and reviewed by managers as part of the annual review process.
Operational Plan Report: Key Priority 1
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1.3 Develop robust reporting against strategic plans.
The first iteration of the SERT Institute Operational Report was published in July 2024 highlighting achievements from January - June 2024. It was endorsed by the Chief Executive and members of the SERT Institute Advisory Committee in August 2024. Subsequent Annual reports will be published and presented to the SERT Institute Advisory Committee for endorsement. In August 2024, the SERT Institute Advisory committee agreed on the production of a SERT Institute Bi-Annual report to highlight achievements across RNSH Surgery facilitated and or supported the SERT Institute. This will replace a limited number of previously produced sub-specialty reports. The first edition of the RNSH Annual Report will be published in 2025.
The Research Activity Report will continue to include all sub-specialties in DoSA and the next iteration will be published in mid 2025.
1.4 Strengthen business acumen and budget performance.
Over the past 12 months, the SERT Institute operated within budget and recruitment against vacancies were promptly facilitated to support continuity of workflows and activity. A six month report against the strategic direction and operational plan was presented and endorsed by the Advisory Committee in August 2024. The next report will cover the full 12 months of 2024.
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Operational Plan Report: Key Priority 1
Key Priority Area 2
Promotion & Engagement
2.1 Raise the profile and presence of the SERT Institute across RNSH The SERT Institute has a public facing website which was redesigned and transitioned to a new platform in 2024. The concept of integration into NSLHD Intranet has been extensively explored and at this point it is unable to be hosted and managed through the NSLHD Communications and Media team. The SERT Institute will continue to align and comply with relevant NSW Health and local multimedia guidelines and policies relating to website management. An intranet landing page will be designed linked to the SERT Institute external website which hosts up-to-date information on each subspecialty service, promotes educational opportunities and research publications. To ensure consistent information and presentation on the SERT Institute website of all surgical departments, a standardised template was designed. Every surgeon was consulted for relevance and accuracy of information posted including links to individual professional websites and private rooms. These are updated annually and as requested “ad hoc” throughout the year. The website showcases achievements, education, training and research initiatives, significant publications, conferences, awards, innovation and quality improvement projects. Data analytics on the SERT Website will be an area expected to expand in 2025-2026.
2.2 Pursue opportunities to showcase surgical achievements and improved outcomes
A key goal is to establish a platform where surgical research and innovative projects can be shared with colleagues and the broader community. It is also hoped this will attract potential benefactors interested in supporting research, quality improvement projects and clinical trials conducted at RNSH. In 2024, the SERT Institute executive team explored several funding opportunities and submitted grant applications to the NHMRC grants programs, The North Foundation open grants and research & innovation program, seeking support to establish a surgical research forum at RNSH. Unfortunately, all applications and internal negotiations with People and Culture for funding were unsuccessful.
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Royal North Shore Annual Surgical Report for January 2023 - June 2024
The SERT Institute proudly presented the first Royal North Shore Annual Surgical Report for January 2023 to June 2024. This document provides an overview of surgical achievements that have been facilitated, or supported by the SERT Institute and DASO Unit over 18 months. It also incorporates achievements against the SERT Institute Operational key priority areas. The report was presented to the NSLHD Chief Executive, NSLHD Board members and proven valuable in facilitating discussion and investment in surgical initiatives such as robotic surgery.
2.3 Strengthen and grow key partnerships, collaborations and networks that advance the SERT Institute vision Key partnerships include: 2021-2022: The SERT Institute initiated a collaboration with WSLHD and USYD to develop a junior consultant leadership program “FLASH”. 2022-2023 (ongoing): Joined Sydney Health Partners surgical research collaboration and network. 2020-2024: strengthened the USYD Masters of Surgery and Clinical Skills Lab - increasing registrations by 200% over this time. Provided sponsorship for the Northern Clinical School Frank Rundle and Patrick Copeland surgical awards 2024-2025: Increased participation in the National and NSW NSQIP Collaborative Network and attended several conferences. Stakeholder engagement: To be reviewed and updated in 2025. Future focus will involve external stakeholder engagement, strengthening collaborations and partnerships in research and increasing sponsorship and philanthropic opportunities for surgical research and clinical trial activity. Discussions commenced with the North Foundation focusing on strategies to increase community engagement and development of promotional material.
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Operational Plan Report: Key Priority 2
2.4 Increase surgeon engagement in non-clinical activities
In 2023, individual consultations and a feedback survey identified a local senior leadership training program was needed to support leadership skills development and the complexity of managing a high performing team. This led to the establishment of the RNSH Surgical Leadership Series - a program designed by surgeons for surgeons. Six sessions were conducted in 2023-2024, including a surgeons social in December 2024, These were held afterhours and well attended.
Planning continues for a minimum of 4 sessions per year including a surgeons social in July 2025.
The SERT Institute also conducts an annual survey, inviting surgeons to provide feedback on the SERT Institute activity and make recommendations for the future focus areas. The advisory committee comprising of clinical, education, and research experts and executive leaders provides guidance on strategic direction, governance, performance and future planning. As the executive sponsor for the SERT Institute, the NSLHD Chief Executive (CE) has established regular meetings with the SERT Institute Director and Manager to identify opportunities to keep the executive teams informed of achievements and collaborations across other facilities.
The SERT Institute leadership team also attend Heads of Department, Grand Rounds, data and research meetings.
2.5 Promote surgical activity and achievements
The SERT Institute reports aim to highlight achievements across all sub- specialty services.
The DASO Unit works closely with each surgical departments to assess clinical audit needs, and strengthen M&M meetings with validated data.
In 2021 and 2023, comprehensive surgical reports for six departments were produced, highlighting activity, innovation, quality improvement projects, research and notable achievements, in addition to presenting regularly at Heads of Department and Grand Rounds.
Operational Plan Report: Key Priority 2
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Key Priority Area 3
Research
3.1 Strengthen the capacity of surgical departments to undertake research In 2023, the SERT Institute conducted a surgeon engagement survey to identify barriers to academia, research and clinical audit. 66% of surgeons responded, with barriers identified include: work life balance, limited resources to support research and clinical audit and a lack of awareness regarding pathways to achieving academic titles. The survey findings were presented and discussed at various forums, shared with the executives and have guided the SERT Institute planning. To support surgeon’s capacity to undertake research and quality improvement activities, the SERT Institute is exploring the establishment of a project support officer that would support ethics applications and monitoring and statistical analysis. In addition, the DASO Unit provides support to departments with no dedicated data resource to improve or develop bespoke databases and facilitate clinical audits, M&M’s, overall patient outcome reporting and research. In 2023-2024, databases were developed for Breast, Hands, Ophthalmology, Burns and Plastics and Colorectal services, in addition to an upgrade to the Orthopaedics Spinal Trauma Database.
A new database was developed to support clinical audit, registry reporting and research projects for the NSLHD Trauma Service.
All well established surgical databases have been reviewed and updated over the past 12 months to align with new information management systems and facilitating automated downloads to improve patient reporting. To ensure data completeness, accuracy and timely data entry into surgical databases, the DASO Unit team provides education and training to medical teams on changeover of terms. They also provide regular audit reports and work with teams improve overall reporting to support clinical reviews, billing and revenue generation. Research guides developed by the SERT Institute project officer and clinical leads in 2021 for junior medical officers and students have been scheduled for review and update in 2025.
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3.2 Foster and promote a collaborative research culture across surgery
In 2020, the inaugural RNSH Surgical Research Activity Report 2018- 2020 was published. This was a compilation of 3 years research across all surgical subspecialties. Following positive feedback, the next iteration covered 2021-2022 and included all DoSA services (ICU, Trauma, Anaesthesia, Pain & Allergy management services). From 2018-2022, RNSH surgeons published over 900 research manuscripts, with over 100% increase in activity in 2022 compared to 2018. The next iteration of the RNSH Research Activity Report will be collated and scheduled for publication in May 2025. This report will cover 2023- 2024 surgical research activity and include all DoSA departments. Thereafter, the report will be published every 2 years.
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Operational Plan Report: Key Priority 3
3.3 Enhance internal and external collaborations and partnerships The RNSH Data Network was established by the DASO Unit in early 2024 to bring together individuals and teams working with data across RNSH. These included teams and individuals from the Analytics and Performance Unit, Intensive Care Unit, Emergency Department, Medical Oncology, Bone Marrow Transplant, Radiation Oncology, Medical imaging and Renal departments, including representatives from Health Information Services. The network aims to foster knowledge sharing, problem solving, collaboration, support and advice. The DASO Unit will host network meetings approximately three times per year. The SERT Institute has representation in the NSLHD Research Committee. Following presentations on Education and Clinical Trials achievements in July 2024, in the SERT Institute Advisory Committee meeting, medical leads were invited and scheduled to present their portfolio achievements to the newly formed NSLHD Board Research, Innovation and Technology sub-committee in early 2025. A key focus area in 2025 will be to strengthen relationships with external research partners and seek opportunities for collaborations and promotion of surgical research.
3.4 Recognise and promote surgical research achievements and researchers through a variety of multi media channels
The RNSH Research Activity Reports are actively promoted through all NSLHD media channels, presented to the NSLHD Board and Executive teams, and disseminated to all surgeons and presented at clinical meetings. The RNSH Research Activity Report highlight the volume of research and quality improvement activity across DoSA by individuals/surgical specialty service in addition to identifying areas for collaboration. A goal of the SERT Institute is to establish an annual surgical research symposium that could showcase the excellent quality and volume of research undertaken across surgery. Invitations will be extended to community stakeholders and potential benefactors interested in supporting research.
Due to the challenge of securing funding, hosting a research symposium has been reprioritised to a low priority goal.
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Operational Plan Report: Key Priority 3
Key Priority Area 4
Education & Training
4.1 Deliver and coordinate quality postgraduate surgical education and training
The SERT Institute has supported the delivery of the Masters of Surgery Program by establishing a dedicated Academic Program Lead position.
This lead provides oversight of the program and manages the clinical skills laboratory (Kolling Institute). Since 2020, there has been a significant increase in enrollments (currently over 100 per year), and an increase in elective subjects from 6 to 20. In 2021, the SERT Institute initiated a collaboration with the WSLHD Research Education Network to develop the medical leadership program - Fostering Leadership Across Systems in Health (FLASH) - specifically for early career consultants. FLASH is a 9 month program conducted across both campuses, targeting senior trainees and junior consultants up to seven years. It is now supported and offered by the NSLHD People & Culture Learning & Development Unit. The transition of the SERT Institute website in 2024 provided the opportunity for surgical departments to promote post-graduate training courses that were being offered by RNSH surgery. In 2024, the Ear Nose and Throat (ENT) surgical team developed and launched the first ENT Emergency Surgery Refresher Course. This is a nationally offered workshop, delivered from the Surgical Skills laboratories located in the Kolling Building on the RNSH Campus. The SERT Institute team worked closely with the ENT surgeons to design and develop a page on the SERT Institute website that would not only promote the course, but also allow interested participants to enquire and register for the workshop. All surgical departmental profiles plus Trauma and Interventional Neuroradiology (INR) services are currently being redesigned on the SERT Institute website using a new template. Surgical education and training opportunities, such as fellowships and specialised courses will be identified through this exercise and promoted on the SERT Institute website.
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4.2 Adopt a clear and transparent framework to determine surgical training pathways across the Northern Campus A surgical learning pathway from medical student to senior consultant will be developed to identify learning requirements at each stage including NSW Health mandatory and local LHD learning requirements.
4.3 Facilitate the growth of clinical leadership
Surgical leadership series:
In 2023, the SERT Institute focused on strengthening medical education, training and leadership. The aim of the RNSH Surgical Leadership Series is to bring surgeons together as a collective to discuss the expectations, challenges and skills required to foster a positive and supportive surgical culture across DoSA that in turn flows into each sub-specialty service. The initiative led by the SERT Institute leadership team, is being designed by surgeons for surgeons through consultation, collaboration, and feedback. This ensures it is sustainable and tailors the series to the needs and expectations of our surgeons. The Leadership Series is an extension of the new consultant leadership program (FLASH) developed in 2021 - a collaboration between WSLHD and NSLHD. A minimum of four leadership development sessions will be conducted per year with the first two sessions held in 2023. A further four sessions were conducted in 2024. All sessions are well attended with approximately 25 participants in each. They were professionally facilitated by Dr Renee Lim, Director of Program Development from the Pam McLean Centre. Themes explored include: leadership models and influences, leadership personalities, styles, conflict resolution, surgical culture and the role, responsibilities and expectations of surgical consultants.
Based on the feedback survey in 2024, a surgeons social gathering event was held on 2 December 2024.
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Operational Plan Report: Key Priority 4
4.4 Establish a high performing team with shared vision and common goals Regular staff meetings and planning sessions are scheduled throughout the year to keep staff informed, seek input and share progress across portfolios and projects. As part of the annual performance review process, all staff complete a GAP analysis survey to identify learning needs. A learning pathway from novice to expert level is in development and individual learning plans are implemented to support progress. A specific data managers manual and orientation program was designed in 2024 with staff consultation and feedback.
Work instructions and processes are regularly documented to ensure consistency and standards of practice are maintained.
4.5 Strengthen workforce capacity and skills through training and education From 2020, the SERT Institute established a Data Network Group and extended an invitation to data management teams across RNSH (medical and surgical services) to join regular Lunch & Learn Sessions. During the COVID pandemic period (2020 to 2023), these moved to online sessions and included morale and team building activities. In 2023, the sessions continued with the introduction of a hybrid model combining both online and face to face options. These sessions provide opportunities to share knowledge, skills and learnings with others, showcase achievements, new projects, and identifying challenges/obstacles data analysists, managers and researchers face and address across different sub-specialty areas.
Operational Plan Report: Key Priority 4
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Key Priority Area 5
Innovation & Quality Improvement
5.1 Identify and promote surgical innovation opportunities
In May 2023, the SERT Institute hosted the second Dr Ray Hollings Surgical Excellence Awards Night. This night was held in conjunction with the Dr Harry Cumberland Travelling Scholarship Award, as part of a collaborative partnership with the RNSH Gastroenterology Department. The night saw over 80 surgeons and distinguished guests in attendance. Three recipients were awarded with the Dr Ray Hollings Surgical Excellence Award, supporting high impact surgical innovation and quality improvement initiatives.
Supporting surgeons funding opportunities
The SERT Institute explored potential funding opportunities to support research and innovation.
In 2024, the SERT Institute helped Dr Leo Pang apply for the Ramsay Research Foundation and secure $27,000 to support his novel Head and Neck Cancer Screening day and enable additional screening days in 2025.
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5.2 Support new and existing surgical innovation and quality improvement programs across RNSH The SERT Institute has supported the Dr Ray Hollings Surgical Excellence Awards recipient's projects throughout their lifecycle from initiation to completion. This includes project planning documentation, ethics applications, design and development of survey and automated booking tools to ensure surgeons are well supported and project milestones and deliverables were met within the expected timeframes. From 2024, the SERT Institute has participated in, and been instrumental in supporting the Surgical Outcomes Committee, providing high level reporting and analysis to facilitate robust interrogation and actions. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) RNSH has experienced an interrupted launch of NSQIP, firstly through the COVID pandemic, and secondly due to the more than an 18-month period during which the clinical reviewer position was unfilled. The program was transferred to the SERT Institute in 2024 followed by recruitment to the surgical champion and clinical reviewer positions. In May 2024, RNSH had the honour of hosting the national NSQIP collaborative meeting. Ongoing participation in NSQIP was approved by the NSLHD Chief Executive in 2025, ensuring commitment to improving surgical patient care and outcomes through a world renowned and reputable improvement program. Surgeon engagement on the future direction of NSQIP and preparation to reinvigorate the program in 2025 is also underway with data collection expected to commence in March 2025. Keeping staff up to date on surgical trends is a high priority for the SERT and DASO teams who have actively participated in the NSQIP collaborative meeting from 2023/2024 to gain insight into initiatives and quality improvement projects across Australian and International hospitals.
Robotic surgery
Planning and negotiations is also underway to introduce and support the implementation of robotic surgery across a number of subspecialties at RNSH in 2025.
The SERT Institute will support data collection and analysis for robotic surgery
Operational Plan Report: Key Priority 5
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5.3 Promote the utilisation of project management tools to plan, develop, implement and evaluation projects.
The SERT Institute and DASO Unit is primarily a paperless department with a high to expert competency level in Microsoft Office Suite, project management, Power BI and statistical analysis tools, REDCap and NSW Health ICT programs. In addition, we promote Agency for Clinical Innovation (ACI) project management tools and Accelerating Implementation Methodology (AIM) and the Clinical Excellence Commission (CEC) Applied Safety & Quality Program. Knowledge of these programs ensures surgical projects are accurately documented, risk assessed, monitored and supported from initiating tools to final reporting.
5.4 Strengthen connections and alignment with stakeholders for project sustainability and scalability To ensure the data needs of RNSH surgical departments are identified and met, a GAP analysis was conducted, that also captured academic and commercial partnerships and accountability to national and state registries. The DASO data managers focuses on strengthening surgeon engagement and improving clinical audits, M&M meetings, documentation compliance and activity reporting which translates to improvement in patient care/outcomes and increased research output. There is enthusiasm across surgery to explore the possibility of the SERT Institute transitioning to a District-wide service and provide a similar level of support to surgeons at both Hornsby and Ryde hospitals. In October 2024, the the NSLHD Clinical Director for Surgery and Anaesthesia approached the SERT Institute to explore the possibility of extending support to Hornsby and Ryde hospitals. The SERT Institute committed to creating surgical profiles for both facilities, a workforce and data GAP analysis. In addition to identifying suitable RNSH databases for adaptation and implementation and resources required to support the implementation, management and sustainability.
The report was presented in the SERT Institute Advisory Committee in November 2024.
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Operational Plan Report: Key Priority 5
Key Priority Area 6
Data & Audit
6.1 Develop and improve surgical reporting processes through embracing new technology capabilities and trends
In 2023-24, the DASO Unit provided support to several departments with no dedicated data resource and support to design and develop a bespoke database for clinical audit and M&M meetings. An example of this is the new Colorectal database which supports a semi-automated data upload from SurgiNet, removing the need for registrars and fellows to input basic demographics and surgery data. A similar process was applied to the Orthopaedics database.
The Hands Department database was expanded to include PROMs and a tracking system for follow-up clinic attendance and PROM compliance.
In 2024, the DASO Unit adopted and applied Microsoft Power BI in several departments to improve reporting and to align with NSLHD reporting systems.
Hospital Acquired Complications (HACs)
The Surgical Outcomes Committee utilises a number of reports to monitor the HACs rate at RNSH. In 2024, the DASO Unit developed a RNSH HACs report which is currently being refined and tailored to each surgical department with surgeon feedback. When finalised, a dashboard will be developed to enable greater insights for each surgical department.
Bespoke database development
Several REDCap databases have also been developed to support departmental audits and research projects in various departments (Ophthalmology, Colorectal, Breast). The Interventional Neuroradiology databases have been redeveloped to streamline data collection that is consistent with the reporting needs of the department. This also sets the foundation for future automation of data from various sources, enabling more efficient and accurate data collection. This will be completed in 2025.
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Surgical Medicare Benefits Schedule (MBS) coding
In order to accurately report on surgical data and support surgical billing, MBS codes are recorded at time of surgery in the operation report.
In April 2024, data discrepancies identified significant errors in documentation and medical team knowledge gaps.
The SERT Institute undertook a review, connecting with finance to identify relevant billing codes and education strategies, address medical knowledge deficits and increase compliance rates. An automated database was created to extract data from the operation report, upload it to a finance repository access by the administration team responsible for data entry. A timeline was created to swiftly close the gap and enter retrospective data gaps for 2022-2023 and 2023-2024 FY generating revenue on Medicare rebate item numbers. Overall compliance has increased at time of surgery and revenue generation. The project remained on track to complete 2022-23 FY missing data by 30 June 2024 and subsequent years.
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Operational Plan Report: Key Priority 6
6.2 Consistent implementation of governance and security measures across surgery data systems and processes
Data governance
The SERT Institute will work closely with the NSLHD Performance Unit on the development of a data governance guideline for NSLHD, to provide transparency on data use, rights, ownership and sharing. An internal DASO Unit data governance procedure has already been developed, providing SERT Institute management staff with guidance on the roles and responsibilities of individuals involved in data collection which aligns with current local and national policies and guidelines. Governance and processes for releasing and sharing information outside of NSLHD are a SERT Institute 2025 priority to develop to safeguard the use of all surgical data.
Out of scope data requests
In 2021, the DASO Unit Data Request Portal was launched for both internal and external stakeholders to lodge a data request. This has allowed the DASO Unit to track additional and out of scope requests.
It is monitored and reported in the SERT Institute annual report and regularly at the SERT Institute management meetings.
In 2023, 63 out-of-scope requests were received. The volume of requests received remained consistent, with 61 out-of-scope requests received in 2024.
Data management manual - for staff
A Data Management Manual was produced in 2024. This is a comprehensive guide for new starters to orient them to NSW Health relevant procedures and guidelines, essential knowledge surrounding how data is collected and used in the health system, and how data reporting impacts activity and funding.
Securing data
The transition of 20 years of historical datasets from excel spreadsheets to new secure databases was completed in 2024 for Pancreatic and Endocrine surgical services.
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Operational Plan Report: Key Priority 6
6.3 Improve engagement and utilisation of available technologies and systems
Single Digital Patient Record (SDPR)
NSLHD will be one of the first districts to go live with the Single Digital Patient Record (SDPR) in 2026 (projected), and the SERT Institute has been acknowledged as well positioned to provide valuable insights into the transition of Cerner eMR to EPIC to ensure the impact on existing reporting processes for surgical department are kept to a minimum.
The NSLHD Chief Executive has expressed interest in the SERT Institute being involved the SDPR working groups.
The SERT Institute staff will attend relevant training as it becomes available to ensure they support the transition.
In 2023-2024, training was also undertaken on “R” statistical analysis, Power BI, Power Automate and NSW Health Enterprise Data Lake and Health systems upgrades.
The Surgical Audit Gateway (SAGE)
The Surgical Audit Gateway (SAGE) was developed by the DASO Unit in 2020-2022 to provide surgical departments with a secure one-stop platform to store sensitive reports, departmental audits and M&Ms and provide a portal for surgeons to access their databases and dashboards. The utilisation of SAGE has continued to be minimal due to several factors, such as access issues and limited utility. This will be monitored further over 2025 and if utilisation remains low consideration will be given to migrate to a new platform. Other secure platforms available include Microsoft TEAMs, OneDrive and Sharepoint.
6.4 Improve clinician knowledge and understanding of clinical audits and processes Currently, there are no local guidelines to inform surgeons on how to perform robust clinical audits and M&M meetings. A guideline for clinical audits and M&Ms will be developed in 2025 with surgical input and consultation to ensure relevancy and promote consistency in clinical audits and M&Ms being conducted at RNSH/NSLHD. This will be developed through consultation with local and district clinical governance and quality units and also medical services, to ensure alignment to current policies and guidelines.
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Operational Plan Report: Key Priority 6
6.5 Maintain a high standard of data quality for reporting accuracy and research
The DASO Unit ensures a high standard of data quality is maintained throughout surgical department they support.
Consultants are regularly engaged in the review of specific databases to determine how the processes and database can be improved in addition to the data collection process, efficiency, clinical relevance, clinical audit compliance, M&M meetings and utilisation for research.
In 2023/2024, the DASO Unit increased the utilisation of coded data to support data requests, aligning to national reporting standards.
Examples of consultation reviews include:
The Orthopaedics department requested support to implement changes to increase junior doctor involvement in accurate data collection and compliance. The DASO Unit provided regular education, monitoring and audit reports for discussion in meetings. The Hands department requested to introduce several data validation processes to track PROMs compliance and data collection/compliance by junior medical officers. Self monitoring and automated reporting tools were developed for downloading by consultants. The Neurosurgery department reviewed definitions for complications currently reported in departmental clinical audits resulting in modifications to the database for clinical relevance and ability to drill down into individual cases in addition to improving ease of use and accessibility. In 2024, a new Ophthalmology database and dashboard was created to track and report on surgical activity, complications and incidents. As this department does not have a data management resource the DASO Unit will review and update this database annually and as requested.
Operational Plan Report: Key Priority 6
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