Evaluation of the implementation of a quality improvement program through morbidity and mortality reviews in a developing country

From Reporting to Improving: How Root Cause Analysis in Teams Shape Patient Safety Culture

Background

Given the increasing focus on patient safety in healthcare systems worldwide, understanding the impact of Continuous Quality Improvement Programs (QIPs) is crucial. QIPs, including Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs), have been identified as effective strategies for enhancing patient safety culture. These programs engage healthcare professionals in the identification and analysis of adverse events to foster a culture of safety (ie the product of individual and group value, attitudes, and perceptions about quality and safety). This study aimed to determine whether patient safety culture differed regarding care provider participation in MMCs and EFCs activities.

Methods

A cross-sectional web-only survey was conducted in 2022 using the Hospital Survey on Patient Safety Culture (HSOPS) among 4780 employees at an 1836-bed, university-affiliated hospital in France. We quantified the mean differences in the 12 HSOPS dimension scores according to MMCs and EFCs participation, using Cohen d effect size. We performed a multivariate analysis of variance to examine differences in dimension scores after adjusting for background characteristics.

Results

Of 4780 eligible employees, 1457 (30.5%) participated in the study. Among the respondents, 571 (39.2%) participated in MMCs or EFCs activities. Participants engaged in MMCs or EFCs reported significantly higher scores in six out of twelve HSOPS dimensions, particularly in "Nonpunitive response to error", "Feedback and communication about error", and "Organizational learning" (Overall effect size = 0.14, 95% confidence interval = 0.11 to 0.17, P<0.001). Notably, involvement in both MMCs and EFCs was associated with higher improvements in patient safety culture compared to non-participation or singular involvement in either program. However, certain dimensions such as "Staffing", "Hospital management support", and "Hospital handoffs and transition" showed no significant association with MMCs or EFCs participation, highlighting broader systemic challenges.

Conclusion

The study confirms the positive association between participation in MMCs or EFCs and an enhanced culture of patient safety, emphasizing the importance of such programs in fostering an environment conducive to learning, communication, and nonpunitive responses to errors. While MMCs or EFCs are effective in promoting certain aspects of patient safety culture, addressing broader systemic challenges remains crucial for comprehensive improvements in patient safety.

Mixed-methods Assessment of Incivility During Surgical Mortality and Morbidity Conference

OBJECTIVE

This study assessed incivility during mortality and morbidity (M&M) conference.

BACKGROUND

A psychologically safe environment at M&M conference enables generative discussions to improve care. Incivility and exclusion demonstrated by "shame and blame" undermine generative discussion.

METHODS

We used a convergent mixed-methods design to collect qualitative data through nonparticipant observations of M&M conference and quantitative data through standardized survey instruments of M&M participants. The M&M conference was attended by attending surgeons (all academic ranks), fellows, residents, medical students on surgery rotation, advanced practice providers, and administrators from the department of surgery. A standardized observation guide was developed, piloted and adapted based on expert nonparticipant feedback. The Positive and Negative Affect Schedule Short-Form (PANAS) and the Uncivil Behavior in Clinical Nursing Education (UBCNE) survey instruments were distributed to the Department of Surgery clinical faculty and categorical general surgery residents in an academic medical center.

RESULTS

We observed 11 M&M discussions of 30 cases, over 6 months with 4 different moderators. Case presentations (virtual format) included clinical scenario, decision-making, operative management, complications, and management of the complications. Discussion was free form, without a standard structure. The central theme was that limited discussion participation from attending surgeon of record, as well as absence of a systems-approach led to blame and then blame then set the stage for incivility. Among 147 eligible to participate in the survey, 54 (36.7%) responded. Assistant professors had a 2.60 higher Negative Affect score ( P =0.02), a 4.13 higher Exclusion Behavior score ( P =0.03), and a 7.6 higher UBCNE score ( P =0.04) compared with associate and full professors. Females had a 2.7 higher Negative Affect Score compared with males ( P =0.04).

CONCLUSION

Free-form M&M discussions led to incivility. Structuring discussion to focus upon improving care may create inclusion and more generative discussions to improve care.

Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery

Morbidity and mortality conferences (MMCs) have evolved beyond their traditional educational role to become instrumental in enhancing patient safety. System-based MMCs offer a unique perspective on patient safety by dissecting systemic factors contributing to adverse events. This paper reviews the impact of MMC in managing postoperative bleeding after gastric and pancreatic cancer surgery, within the constraints of limited resources. The study conducted at the National Institute of Oncology in Rabat, Morocco, analysed 18 MMC of haemorrhage following gastric and pancreatic surgeries and allowed to identify two patterns of cumulative factors contributing to adverse events. The first one relates to organisational issues and the second to postoperative management. Fifteen recommendations of improvement emerged from MMC addressing elements of these patterns with an implementation rate of 53.3%.

Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature

Objective

This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes.

Background

Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts.

Methods

A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted.

Results

Seven studies were identified. Key TBMM elements were identified, including activities done before the conference-case selection and case investigation; during the conference-standardized presentation formats and formal moderators; and after the conference-follow-up emails and quality improvement projects. The impacts of TBMMs on educational, safety, and quality improvement outcomes were heterogeneous, and no meta-analysis could be conducted; however, improvement was typically shown in each of these domains where comparisons were made.

Conclusions

Recommendations for key TBMM elements can be drawn from the reports of successful perioperative TBMMs. Possible benefits of structured TBMMs over single-discipline conferences were identified for further exploration, including opportunities for rich educational contributions for trainees, improved patient safety, and the potential for system-wide quality improvement. Design and implementation of TBMM should address meticulous preparation of cases, standardized presentation format, and effective facilitation to increase the likelihood of realizing the potential benefits.