Morbidity and mortality conference as part of PDCA cycle to decrease anastomotic failure in colorectal surgery

Systematic Review of Morbidity and Mortality Meeting Standardization: Does It Lead to Improved Professional Development, System Improvements, Clinician Engagement, and Enhanced Patient Safety Culture?

OBJECTIVES

This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture.

METHODS

Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies.

RESULTS

After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms.

CONCLUSIONS

There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.

Head and neck cancer patient journey's health literacy: a multidisciplinary team perspective. VOICE study

PURPOSE

Health literacy is a current Public Health priority in Portugal. The participation of well-informed patients in their care and shared decision making are essential, especially in chronic aggressive and debilitating pathologies such as recurrent or metastatic (R/M) Head and Neck Squamous Cell Carcinoma (HNSCC).

AIMS

This study aimed to characterize R/M HNSCC patients' and caregivers' information needs identified by healthcare professionals (HCPs).

METHODS

Two online Focus Groups, one with only medical doctors and the other with other HCPs involved in the treatment of R/M HNSCC patients, were conducted, using a modified Metaplan, Lean or adapted PDCA methodology. The discussions were audio recorded in full and content analysis was performed using ATLAS.ti qualitative data analysis software.

RESULTS

Topics addressed were diagnosis, treatment, quality of life, and global evaluation. In general, all experts agreed that only essential information should be cautiously given, according to patients' and caregivers' wishes. It was consensual that patients are given the necessary information to adhere to treatment. Two main barriers were identified: one barrier was associated with verbal communication due to the lack of health literacy of these patients, and the other barrier regarded healthcare access. It was also considered important to remind patients of the daily and social activities that they could and should maintain, as well as providing sufficient social resources and problem-solving training to caregivers.

CONCLUSIONS

This qualitative study highlights the complexity of R/M HNSCC patients' care. Immediate availability of psychologists and psychiatrists should be implemented in all centers that treat HNSCC patients. The differences found between the physicians' Focus Group and other HCPs' Focus Group in some of the addressed topics emphasize the importance of a multidisciplinary and holistic approach, in a biomedical model integrated with a biopsychosocial model.

Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review

Importance

Morbidity and mortality conferences (MMCs) are thought to advance trainee education, quality improvement (QI), and faculty development. However, there is considerable variability with regard to their completion.

Objective

To compile and analyze the literature describing the format, design, and other attributes of MMCs that appear to best advance their stated objectives related to QI and practitioner education.

Evidence Review

For this systematic review, a literature search with terms combining conference and QI or morbidity and mortality was performed in January 2022, using the PubMed, Embase, and ERIC (Education Resources Information Center) databases with no date restrictions. Included studies were published in English and described surgical or nonsurgical MMCs with explicit reference to quality or system improvement, education, professional development, or patient outcomes; these studies were classified by design as survey based, intervention based, or other methodologies. For survey-based studies, positively and negatively regarded attributes of conference design, format, and completion were extracted. For intervention-based studies, details of the intervention and their impact on stated MMC objectives were abstracted. Principal study findings were summarized for the other group. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Abstract screening, full-text review, and data extraction and analysis were completed between January 2022 and December 2022.

Findings

A total of 59 studies met appropriateness for study inclusion. The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality. The evidence suggested that preparation and postconference follow-up regarding QI initiatives are equally as important as both (1) succinctly presenting case details, opportunities for improvement, and educational topics and (2) creating a constructive space for accountability, engagement, and multistakeholder discussion.

Conclusions and Relevance

These findings suggest that the published literature on MMCs provides substantial insight into the optimal format, design, and related attributes of an effective MMC. This systematic review provides a road map for surgical departments to improve MMCs in order to align their format and design with their principal objectives related to practitioner and trainee education, error prevention, and QI.

Effective peer review audit and identification of the surgeon outlier

BACKGROUND

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit.

METHODS

All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT).

RESULTS

A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored.

CONCLUSION

The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Cyclic workflow to improve implementation of learning points from morbidity and mortality meetings

BACKGROUND

Morbidity and mortality meetings (M&MMs) are organized in most hospital departments with an educational purpose to learn from adverse events (AEs) to improve patient care. M&MMs often lack effectiveness due to unsuccessful systematic follow-up of areas of improvement. This can have an effect on improving patient safety and care. Therefore, a new strategy that focuses on implementing areas of improvement into daily practice is necessary. The study aim is to see if we could improve the implementation of meeting outcomes from the M&MM by using a cyclic workflow, and which factors are important to achieve its implementation.

METHODS

This prospective study took place at the department of gynecologic oncology of a university hospital. Research was conducted with a participatory action research (PAR) approach using 10 consecutive M&MMs in 2019 and 2020. The cyclical workflow consisted of an action list based on the PDCA-cycle, a check of the implementation of areas for improvement at the next M&MM and regular monitoring of tasks. Each M&MM was observed and each professional with an assigned task was interviewed and gave their informed consent. Thematic content analysis was performed with the program Atlas.ti 8.4.20.

RESULTS

Out of the 39 tasks that resulted from 10 M&MMs, 37 (94.8%) followed all the steps in the PDCA-cycle and were implemented. In total, 16 interviews were conducted with consultants, nurses, registrars and residents. Five main factors were important to achieve follow-up of areas for improvement: organizational culture, motivation, commitment, communication to mobilize employees and skills. Repetition of the cyclic workflow at the M&MM and an external person who reminded professionals of their assigned task(s) was important to change habits and motivate professionals.

CONCLUSION

Cyclical tools can support the implementation of areas for improvement to optimize the M&MM. A M&MM with an organizational culture where attendees can discuss openly and freely may motivate attendees to take on tasks successfully. A positive stimulant to reach commitment of professionals is team participation. Integrating new habits of reflection may lead to a deeper level of learning from the PDCA-cycle and of the M&MM. Creating a learning environment outside of the M&MM may support professionals to take on actions and engage in improvement practices. Future research may focus on including a comparative analysis to show a success rate of the implementation of learning points from the M&MM more clearly.

Changes in the Quality of Life, Psychological Status, Medication Compliance, and Prognosis of Patients with Acute Myocardial Infarction after PCI by Applying PDCA Cycle Management Model

Objective

To discuss the changes in the quality of life, psychological status, medication compliance, and prognosis of patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI) by applying plan-do-check-action (PDCA) cycle management model.

Methods

A total of 125 patients with AMI who underwent PCI in our hospital from June 2018 to June 2020 were selected and divided into control group (n = 62) and research group (n = 63) by the random number method. The conventional nursing measures were used in the control group, and the PDCA cycle management model on the basis of the control group was used in the research group. The changes in the quality of life, psychological status, medication compliance, and prognosis were observed.

Results

After intervention, the Generic Quality of Life Inventory-74 scores and the self-made medication compliance questionnaire score of the research group were higher than the control group (P < 0.05). After intervention, the self-rating anxiety scale score and self-rating depression scale score of the research group were lower than those of the control group (P < 0.05). The total incidence of adverse events in the research group (7.94%) was lower than that in the control group (20.97%) (P < 0.05).

Conclusion

After the application of PDCA cycle management model, the quality of life, psychological status, medication compliance, and prognosis of AMI patients who underwent PCI were improved.

[Evidence of Improved Patient Safety in Germany]

Since 2015, the requirement for data transparency has been met in Germany by publishing structured quality reports in licensed hospitals, but one of the main concerns of patients, namely treatment safety, has not been a prominent feature of these reports. Therefore, this study was undertaken to find out what examples of improved patient safety have been published in Germany in the last 10 years. A systematic literature search identified 10 studies which highlight the quantitatively measured success of 13 interventions.

Transforming surgical morbidity and mortality into a systematic case review

BACKGROUND/PURPOSE

The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement.

METHODS

An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019.

RESULTS

For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content.

CONCLUSION

Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review.

TYPE OF STUDY

Retrospective Historical control; Quality improvement.

LEVEL OF EVIDENCE

Level III.

Continuous improvement process: ortho-geriatric co-management of proximal femoral fractures

OBJECTIVE

The objective of the current study was to evaluate the effect of a quality management system on treatment and care delivery of proximal femoral fractures. Specifically, our hypothesis was that the "plan-do-check-act (PDCA)" philosophy of the ISO 9001 quality management system results in a continuous improvement process.

METHODS

1015 proximal femoral fractures were prospectively included into a hip fracture database over a 5-year period, after a restructuring process with implementation of clinical pathways and standard operation procedures. A close and structured ortho-geriatric co-management (certified ortho-geriatric center) was the basis for treatment. ISO 9001 certification was granted for the first time in 2012. Procedural and patient outcome parameters were analyzed by year and evaluated statistically using SPSS 25.0.

RESULTS

In both categories (procedural and outcome) significant changes could be detected during the 5-year period, e.g., significant reduction of time to surgery for the first 2 years, improvement in discharge management, and reduction of surgical complications. However, no significant changes could be demonstrated for mortality or internal complications such as pneumonia, urinary tract infections, or postoperative delirium. However, the incidence of the latter was already on a very low level at the onset of the quality improvement process.

CONCLUSION

We could show a relevant and continuous improvement of several quality indicators during a 5-year period after implementation of a quality management system based on the PDCA philosophy for the treatment of proximal femoral fractures in elderly patients. However, other parameters (internal complications, cost-effectiveness, etc.) need our close attention in the future.

[Cognitive errors in diagnostic decision making]

Approximately 10-15% of our diagnostic decisions are faulty and may lead to unfavorable and dangerous outcomes, which could be avoided. These diagnostic errors are mainly caused by cognitive biases in the diagnostic reasoning process.Our medical diagnostic decision-making is based on intuitive "System 1" and analytical "System 2" diagnostic decision-making and can be deviated by unconscious cognitive biases.These deviations can be positively influenced on a systemic and an individual level. For the individual, metacognition (internal withdrawal from the decision-making process) and debiasing strategies, such as verification, falsification and rule out worst-case scenarios, can lead to improved diagnostic decisions making.

The role of morbidity and mortality rounds in medical education: a scoping review

CONTEXT

There is increasing focus on how health care professionals can be trained effectively in quality improvement and patient safety principles. The morbidity and mortality round (MMR) has often been used as a tool with which to examine and teach care quality, yet little is known of its implementation and educational outcomes.

OBJECTIVES

The objectives of this scoping review are to examine and summarise the literature on how the MMR is designed and delivered, and to identify how it is evaluated for effectiveness in addressing medical education outcomes.

METHODS

A literature search of the PubMed, MEDLINE, PsycInfo and Cochrane Library databases was conducted for articles published from 1980 to 1 June 2016. Publications in English describing the design, implementation and evaluation of MMRs were included. A total of 67 studies were identified, including eight survey-based studies, four literature reviews, one ethnographic study, three opinion papers, two qualitative observation studies and 49 case studies of education programmes with or without formal evaluation. Study outcomes were categorised using Donald Moore's framework for the evaluation of continuing medical education (CME).

RESULTS

There is much heterogeneity within the literature regarding the implementation, delivery and goals of the MMR. Common design components included explicit programme goals and objectives, the case selection process, case presentation models and some form of case analysis. Evaluation of CME outcomes for MMR were mainly limited to learner participation, satisfaction and self-assessed changes in knowledge.

CONCLUSIONS

The MMR is widely utilised as an educational tool to promote medical education, patient safety and quality improvement. Although evidence to guide the design and implementation of the MMR to achieve measurable CME outcomes remains limited, there are components associated with positive improvements to learning and performance outcomes.

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System

BACKGROUND

Recent improvements to morbidity and mortality (M&M) conference have focused on the case review system. However, case selection occurs by physician reporting, which is limited by selection bias. We compared the effectiveness of our M&M conference with the NSQIP-Pediatric (NSQIP-P) system for identifying adverse events.

STUDY DESIGN

Complications from January 2010 to September 2015 were compared between M&M and NSQIP-P. Only M&M patients meeting NSQIP-P criteria were compared with patients from the NSQIP-P system; exclusions were studied separately. Complication rates in M&M conference before and after a 2012 format change designed to increase case reporting were also compared.

RESULTS

Detection of mortality in M&M conference and NSQIP-P was not different. Morbidity events identified by NSQIP-P were significantly higher than M&M conference during the entire study period (194 vs 100 occurrences/1,000 cases) (p < 0.0001). Morbidity occurrences in M&M conference increased with the 2012 improvements, however, they still remained less than that identified by NSQIP-P (226 vs 141 occurrences/1,000 cases) (p < 0.0001). Of 863 patients presented in M&M conference, 210 were excluded from direct comparison because they did not meet NSQIP-P criteria. These included 62 deaths and 287 occurrences of morbidity. Their analysis in M&M conference resulted in 32 action initiatives directed at system failures.

CONCLUSIONS

The NSQIP-P identified more complications than M&M. The M&M conference improvements increased reported cases, but they still remained lower than NSQIP-P. However, M&M conference identified events resulting in systems changes that would not have been identified by NSQIP-P. Although NSQIP-P captures occurrences to compare large patient cohorts, M&M analyzes singular failures and initiates direct interventions. Integration of these systems can optimize their usefulness in quality improvement.

Reduction and sustainability of cesarean section surgical site infection: An evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program

BACKGROUND

We found cesarean section (C-section) surgical site infection (SSI) at our institution was significantly higher than the national benchmark.

METHODS

A retrospective cohort study was conducted under 4 phases from January 2008-December 2014. The hospital infection control (IC) policies and a presurgical checklist were bundled and implemented. The study was conducted with 3,334 cesarean deliveries: phase A (January 1, 2008-January 31,2010): 1,250 patients without intervention (baseline SSI rate), phase B (February 1, 2010-July 31, 2011): 682 patients were intervened with IC policies, phase C (August 1, 2011-December 31, 2012): 591 patients with an SSI reduction bundle, and phase D (January 1, 2013-December 31, 2014): 811 patients were monitored for C-section SSI sustainability. Patients not following strict protocols because of emergency C-section deliveries were excluded. The χ² test, Fisher exact test, and standard Z test were used for statistical analyses.

RESULTS

C-section SSI rates were 6.2% (77/1,250) in phase A, 3.7% (25/682) in phase B, 1.7% (10/591) in phase C, and 0.1% (1/811) in phase D, respectively. By implementing the IC policies and bundle, the C-section SSI rate was reduced 40.3% (phase B vs phase A), 72.6% (phase C vs phase A), and 98.4% (phase D vs phase A). All statistics were significantly different.

CONCLUSIONS

We conclude that implementing a C-section SSI reduction bundle was associated with reduced C-section SSI rate down toward zero. A future prospectively randomized controlled trial is warranted.

Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference

BACKGROUND/PURPOSE

The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care.

METHODS

A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items.

RESULTS

Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.

CONCLUSIONS

Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.

Surgery and Medicine Residents' Perspectives of Morbidity and Mortality Conference: An Interdisciplinary Approach to Improve ACGME Core Competency Compliance

OBJECTIVE

Morbidity and mortality conferences (MMCs) are often used to fulfill the Accreditation Council for Graduate Medical Education practice-based learning and improvement (PBLI) competency, but there is variation among institutions and disciplines in their approach to MMCs. The objective of this study is to examine the trainees' perspective and experience with MMCs and adverse patient event (APE) reporting across disciplines to help guide the future implementation of an institution-wide, workflow-embedded, quality improvement (QI) program for PBLI.

DESIGN

Between April 1, 2013, and May 8, 2013, surgical and medical residents were given a confidential survey about APE reporting practices and experience with and attitudes toward MMCs and other QI/patient safety initiatives. Descriptive statistics and univariate analyses using the chi-square test for independence were calculated for all variables. Logistic regression and ordered logistic regression were used for nominal and ordinal categorical dependent variables, respectively, to calculate odds of reporting APEs. Qualitative content analysis was used to code free-text responses.

SETTING

A large, multihospital, tertiary academic training program in the Pacific Northwest.

PARTICIPANTS

Residents in all years of training from the Accreditation Council for Graduate Medical Education-accredited programs in surgery and internal medicine.

RESULTS

Survey response rate was 46.2% (126/273). Although most respondents agreed or strongly agreed that knowledge of and involvement in QI/patient safety activities was important to their training (88.1%) and future career (91.3%), only 10.3% regularly or frequently reported APEs to the institution's established electronic incident reporting system. Senior-level residents in both surgery and medicine were more likely to report APEs than more junior-level residents were (odds ratio = 4.8, 95% CI: 3.1-7.5). Surgery residents had a 4.9 (95% CI: 2.3-10.5) times higher odds than medicine residents had to have reported an APE to their MMC or service, and a 2.5 (95% CI: 1.0-6.2) times higher odds to have ever reported an APE through any mechanism. The most commonly cited reason for not reporting APEs was "finding the reporting process cumbersome." Overall, 87% of respondents agreed or strongly agreed that MMCs were valuable, educational, and contributed to improving patient outcomes, but many cited opportunities for improvement.

CONCLUSIONS

Although the perceived value of MMCs is high among both surgical and medicine trainees, there is significant variability across disciplines and level of training in APE reporting and experience with MMCs. This study presents a multidisciplinary resident perspective on optimizing APE reporting, MMCs, and PBLI compliance.

Development of an integrated support system for hereditary cancer and its impact on gynecologic services

OBJECTIVE

Patients with hereditary cancer need an integrated support system. A recently launched project was evaluated in terms of its efficacy in screening patients with hereditary cancer at the gynecologic service.

METHODS

The project team comprised gynecologists, surgeons, medical geneticists, and certified genetic counselors (CGCs) in our hospital. At the gynecologic service, a newly developed self-administered family history questionnaire (SAFHQ) was given to patients with ovarian, endometrial, or breast cancer as well as a history of multiple cancers. After an interview, a CGC constructed a pedigree and evaluated the risk for hereditary cancer. Patients at risk were recommended by a gynecologist to receive further genetic counseling at the Department of Genetics according to the modified Bethesda criteria, Amsterdam II criteria, and National Comprehensive Cancer Network (NCCN) guidelines 2012 for breast-ovarian cancer syndrome (HBOC). The numbers of newly screened patients were compared before and after the project launch.

RESULTS

The SAFHQ was administered to 131 patients and 106 (81 %) pedigrees were constructed between August 2012 and July 2013. The number of newly screened patients according to the Bethesda criteria was 4 and 8 at 10 years before and 1 year after the project launch, respectively. Two and 31 patients met the NCCN criteria for HBOC excluding ovarian cancer alone, respectively, at these 2 time points. Of 54 patients who were recommended to undergo further counseling, 10 (19 %) visited the Department of Genetics.

CONCLUSION

After the launch of an integrated support system, the number of patients with hereditary cancers who were screened increased. The gynecologic service played a pivotal role in patient and family care.