Improvement in educational effectiveness of morbidity and mortality conferences with structured presentation and analysis of complications

Reframing the Morbidity and Mortality Conference: The Impact of a Just Culture

ABSTRACT

Morbidity and mortality (M&M) conferences are prevalent in all fields of medicine. Historically, they arose out a desire to improve medical care. Nevertheless, the goals of M&M conferences are often poorly defined, at odds with one another, and do not support a just culture. We differentiate among the various possible goals of an M&M and review the literature for strategies that have been shown to achieve these goals. Based on the literature, we outline an ideal M&M structure within the context of just culture: The process starts with robust adverse event and near miss reporting, followed by careful case selection, excluding cases solely attributable to individual error. Prior to the M&M, the case should be openly discussed with involved members and should be reviewed using a selected framework. The goal of the M&M should be selected and clearly defined, and the presentation format and rules of conduct should all conform to the selected presentation goal. The audience should ideally be multidisciplinary and multispecialty. The M&M should conclude with concrete tasks and assigned follow-up. The entire process should be conducted in a peer review protected format within an environment promoting psychological safety. We conclude with future directions for M&Ms.

The Morbidity and Mortality Conference: A Century-Old Practice with Ongoing Potential for Future Improvement

OBJECTIVE

 To discuss practical strategies to consider for morbidity and mortality conferences (M&M).

MATERIALS AND METHODS

 This article reflects on (i) insights that can be drawn from the M&M literature, (ii) practical aspects to consider when organizing M&M, and (iii) possible future directions for development for this long-standing practice for routine reflection.

RESULTS

 M&M offers the opportunity to learn from past cases in order to improve the care delivered to future patients, thereby serving both educational and quality improvement purposes. For departments seeking to implement or improve local M&M practice, it is difficult that a golden standard or best practice for M&M is nonexistent. This is partly because comparative research on different formats is hampered by the lack of objective outcome measures to evaluate the effectiveness of M&M. Common practical suggestions include the use of (i) a skillful and active moderator; (ii) structured formats for case presentation and discussion; and (iii) a dedicated committee to guide improvement plans that ensue from the meeting. M&M practice is affected by various sociological factors, for which qualitative research methods seem most suitable, but in the M&M literature these are sparsely used. Moreover, aspects influencing an open and blame-free atmosphere underline how local teams should tailor the format to best fit the local context and culture.

CONCLUSION

 This article presents practice guidance on how to organize and carry out M&M This practice for routine reflection needs to be tailored to the local setting, with attention for various sociological factors that are at play.

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

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.

The Hawthorne Effect: Quality and Outcomes in Neurosurgery

Measure something, and it gets better-this is what is called as the Hawthorne effect (also known as the observer effect). The Hawthorne factory experiments in 1920s were remarkable industrial data collection and analysis exercises that lead to Edwards Deming's quality revolution. The Harvard Medical Practice Study (1991), Leape's "Error in Medicine" (1994), and the Bristol pediatric cardiac report (2001) are among many documents that have revealed the huge gap between best practices and actual medical practice. Alarmed by the poor standards of quality at the most respected institutions, the medical fraternity therefore began visiting facilities in different fields and observing their quality assessment processes. The next leap for neurosurgery is to realize that it is unacceptable to treat patients with no regard for the standard of clinical outcomes. The traditional neurosurgery residency training has long ignored the most important issues of self-assessment, reappraisal, relearning, and measurement of skill and surgical outcomes. However, the experience taken from disparate fields, especially cardiac surgery, may encourage research and progress in measurement and improvement of quality in neurosurgery. Like cardiac surgeons, neurosurgeons must examine and analyze the results of their interventions. The concept of quality measurement is the most important single advance we can make in neurosurgery practice. Meticulous and precise measurement of outcomes will allow future progress of our specialty.

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

Background

Morbidity and mortality reviews represent an opportunity to discuss adverse events and healthcare issues. Aim: Report the first experience of implementing a procedure of MMR, and assess its impact on quality improvement.

Methods

From July 2019 to December 2019, members of the surgical and ICU departments designed and implemented a regular procedure of MMR. Cases of severe postoperative complications after curative resection for digestive cancer were selected to be presented by a surgical resident and discussed in an interdisciplinary conference following a standardized presentation based on an analysis tool adapted from the ALARM framework. Process was assessed by the number of MMRs held, number and type of recommendations issued and implemented.

Results

Among 13 serious complications during the study period, 10 were discussed. The “Tasks” category was activated in 90% of the cases where lack or misuse of protocols was identified in 90% of the events discussed. Test results availability or accuracy were incarnated in 30% of cases. Poor communication was a contributing factor in 60% of the cases. Written medical records were defective in 40% of the cases. From 16 recommendations for improvement emitted, 87.5% (14/16) were translated into projects and successfully implemented.

Conclusions

a standardized and regular procedure of morbidity and mortality reviews in a tertiary care facility in a developing country allowed a significant improvement in patient care through quality initiatives implementation. MMRs might be a strong tool for the improvement of surgical care particularly for low-mid income countries.

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Morbidity and mortality reviews (MMR) are an opportunity to discuss adverse events and healthcare issues.

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Experience of implementing a procedure of MMR in a tertiary care facility in a developing country.

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A standardized and regular procedure allowed a significant improvement in patient care through quality initiatives.

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MMR might be a strong tool for the improvement of surgical care particularly for low-mid income countries.

Measuring What Matters at Morbidity and Mortality Conferences: A Scoping Review of Effectiveness Measures

OBJECTIVE

Efforts to study morbidity and mortality conferences (M&MC) are hampered by the lack of rigorous instruments to assess the effectiveness of the conferences for the purpose of quality improvement and medical education. This might limit further advancement of the practice. The aim of this scoping review was to determine commonly used effectiveness measures of M&MC in the literature.

METHOD

A scoping review was performed of quantitative, qualitative, and mixed methods studies of M&MC, using databases from PubMed, Emcare, Embase, Web of Science, and the Cochrane library. Studies were included if an outcome was described after a general evaluation or an intervention to M&MC. Study quality was assessed with the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

A total of 43 articles were included in the review. The majority used a quantitative (n = 23) or mixed (n = 17) design, with surveys as the most frequent method used for data collection (n = 29). The overall Quality Assessment Tool for Studies with Diverse Designs scores were modest (64%). Outcome measures used to evaluate the effectiveness of M&MC were clustered in the following categories: "participant experiences," "characteristics of the meeting," "medical knowledge," "actions for improvement," and "clinical outcomes."

CONCLUSIONS

This review found a wide variety of effectiveness measures for M&MC. Rather than using isolated measures, approaches that combine multiple effectiveness measures could offer a more comprehensive assessment of M&MC. Although there was a preference for quantitative metrics, this fails to seize the opportunity of qualitative methods to yield insights into sociological purposes of M&MC, such as building professional identities and safety culture.

The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety

ABSTRACT

Since the 20th century, health care institutions have used morbidity and mortality conferences (MMCs) as a forum to discuss complicated cases and fatalities to capitalize on lessons learned. Medical technology, health care processes, and the teams who provide care have evolved over time, but the format of the MMC has remained relatively unchanged. The present article outlines 5 key areas for improvement within the MMC along with prescriptive and actionable recommendations for mitigating these challenges. This work incorporates the contributions of numerous researchers and practitioners from the educational, training, debrief, and health care fields. With the best practices and lessons learned from various domains in mind, we recommend optimizing the MMC by (1) encouraging a culture that leverages expertise from multiple sources, (2) allocating ample time for innovative thinking, (3) using a global approach that considers individual, team, and system-level factors, (4) leveraging learnings from errors as well as near misses, and (5) promoting communication, innovative thinking, and actionable planning. The 5 evidence-based recommendations herein serve to ensure that MMCs are structured learning events that promote, encourage, and support safe, reliable care. Furthermore, the outlined recommendations seek to capitalize upon the MMC's opportunity to engage early discovery as well as proactive risk assessment and action-oriented solutions.

Mortality and Morbidity rounds in neonatology: Providers' experiences and perspectives

AIM

To describe how Canadian level III neonatal intensive care units (NICU) organise mortality and morbidity rounds (M&MR) and explore clinicians' perspectives.

METHODS

This questionnaire study, including open-ended questions, examined the following domains: (1) M&MR format, (2) ethical issues and (3) limitations and perceived effectiveness.

RESULTS

Sixteen out of twenty (80%) level III NICUs participated. All deaths and 64% of morbidities were discussed. M&MR occurred monthly (69%) with 3-5 patients discussed hourly (63%) and usually (75%) physician led. Wide variations of practice between centres existed for practical issues, such as administrative support and attendance. 44% of centres allowed nurses to participate. Goals reported by participants were also heterogeneous: reducing medical error (56%), educational (50%), improving communication (44%) and peer review (23%). Practical barriers were time (75%) and lack of resources/structure (25%). Four main themes were as follows: the role of M&MR, the ongoing blame culture, communication issues and the distinction between mortality and morbidity.

CONCLUSION

Goals and format of M&MR vary widely. M&MR remains physician-centric, where the blame culture still endures. Neonatal M&MR models should be adapted to the modern NICU to ensure the M&MR stays relevant. It could also benefit from lessons learned in quality improvement.

Evolving from Morbidity and Mortality to a Case-based Error Reduction Conference: Evidence-based Best Practices from the Council of Emergency Medicine Residency Directors

Morbidity and mortality conferences are common among emergency medicine residency programs and are an important part of quality improvement initiatives. Here we review the key components of running an effective morbidity and mortality conference with a focus on goals and objectives, case identification and selection, session structure, and case presentation.

Participants' Opinion about Conduct of Morbidity and Mortality Conferences in Surgical Practice in a Tertiary Hospital, Ethiopia

Background

Morbidity and mortality conference has both educational and quality improvement purposes. However clear evidences for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking.

Methods

A facility based cross sectional study was conducted at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, to assess participants' opinion on benefits and functioning of morbidity and mortality conferences. Univariate analysis was used to determine the influence of professional type on participants' opinion about the morbidity and mortality conferences.

Result

A total of 98 participants completed the survey. The majority of the participants agreed that there was a structured system of case identification (67.3%), meeting format (72.4%), the conferences were conducted every month (79.6%), it is blame free (71.4%) and system of care was focus of discussion (70%). Most (88.8%) participants agreed that the conferences were important for improvement of patient safety and quality of care, whereas 67.3% of the participants believed that there is no written term of reference and prior dissemination of agendas. Only 40% agreed that there is multidisciplinary team involvement. Fifty one percent of them disagreed that there is a follow up on the implementation of the forwarded recommendations.

Conclusion

Even though the majority of the participants were satisfied with the mortality and morbidity conferences, most disagreed on the presence of written term of reference, earlier dissemination of agendas, multidisciplinary team involvement and follow up on the implementation of the forwarded recommendations.

Enhancing the Educational Value and Faculty Attendance of a Morbidity and Mortality Conference

OBJECTIVE

There exists significant variation in the approach to and execution of morbidity and mortality conference (M&MC). Faculty attendance remains a working challenge. We sought to change our department's M&MC and hypothesized improved educational value and attendance.

DESIGN

Complications were submitted in Clavien-Dindo format. A designated M&MC moderator facilitated discussion. A teaching point (TP) was assigned to each complication intended to be the focus of discussion. Presentations followed a structured 6-slide PowerPoint template. A web-based tool using Google Forms was developed and distributed as an "App" for tracking of attendance. An anonymous online survey was distributed to participants to elucidate perception of M&MC following the intervention.

SETTING

Academic medical center.

PARTICIPANTS

Postgraduate year-1 to 5 surgery residents and faculty at West Virginia University, Morgantown.

RESULTS

Forty-eight of sixty-three surveys were returned (response rate 76%). Twenty-five faculty (70%) and 23 residents (82%) responded. A predetermined TP was viewed as the most favorable change made by both faculty and residents. 65% of faculty and residents acknowledged improved educational value, 58% found a single moderator to help streamline Morbidity and Mortality (M&M) presentations and 71% felt that a standard PowerPoint template improved quality of presentations. Both residents (96%) and faculty (68%) believed a predetermined TP improved the educational value of the conference and medical knowledge during preparation. More residents (43%) than faculty (16%) believed that changes to the department's M&MC format allowed better identification of quality improvement issues. Furthermore, the majority of residents (83%) believed that changes to the department's M&M format allowed better identification of system factors compared to faculty (32%), p = 0.003. Faculty participation increased from 60% to 80% after changes (p = 0.03).

CONCLUSIONS

The educational value of M&MC and attendance can be improved with simple changes, but faculty and residents may have different expectations and perceptions.

Development of the 'People-Processes-Paradigm' critical analysis tool for mortality and morbidity reviews: improving understanding of systems factors

BACKGROUND

The impact of systems problems and human factors on delivering safe, high-quality patient care is well recognized. In the surgical setting, mortality and morbidity reviews (MMRs) are the key forum for reviewing and analysing adverse events in patient care yet there is a paucity of simple tools for undertaking such analyses. The aim of this study was to develop and pilot a new tool for analysing mortality and morbidity cases incorporating human factors and systems analysis.

METHODS

The published literature, professional standards, guidelines and existing audit tools for MMRs were reviewed. The 'People-Processes-Paradigm' tool was developed and pilot testing was undertaken and stakeholder feedback was obtained.

RESULTS

Models found for undertaking systems-based analysis of adverse surgical events included the 3D model, SEIPS and the Queensland Health human error and patient safety (HEAPS) Incident Management Tool. Guidelines for standards in MMRs are provided by the Royal Australasian College of Surgeons, New South Wales Clinical Excellence Commission and Australia and New Zealand audit of surgical mortality (ANZASM). The People-Processes-Paradigm model incorporates these standards and evidence-based systems analysis tools into a single effective tool. The pilot study evaluating the use of this tool demonstrated it to be practical and easily applicable to regular use by clinicians, with the ability to be tailored to individual health service use. Improvements such as electronic format and clarification of case selection processes were recommended by users.

CONCLUSION

The People-Processes-Paradigm tool has been developed for surgeons by surgeons incorporating current professional, legal and regulatory requirements in Australasia, easily transferrable to electronic platforms. This model requires further testing for validation.

Medical Student Involvement and Learning Objectives in Morbidity and Mortality Conferences: A National Survey of the Association for Surgical Education's Committee of Clerkship Directors

BACKGROUND

Despite implementation of Morbidity and Mortality (M&M) Conference across surgical graduate medical education, sparse literature exists regarding the attendance and involvement of medical students. We sought to examine student involvement and learning objectives for M&M on a national level.

METHODS

A survey was distributed through the Association for Surgical Education Committee of Clerkship Directors. Questions examined demographics, teaching practices regarding M&M, and student learning objectives.

RESULTS

Forty-eight responses were collected reflecting practices of weekly M&M (96%) and required student attendance (93%). Students are observers in 61% of M&Ms, observer with questions in 37%, and presenter at 2%. Learning objectives for M&M highlighted exposing students to conference style (76%), reflective learning (63%), and highlighting medical error (78%).

CONCLUSIONS

It is the national standard for medical students to attend weekly M&M. Student learning objectives reflect desires to improve exposure to this style of teaching conference and understanding the gravity of medical error.

Year-to-year trends in emergency medicine morbidity and mortality cases

BACKGROUND

Morbidity and Mortality (M&M) rounds are peer review conferences during which cases with adverse outcomes and difficult management decisions are presented. Their primary objective is to learn from complications and errors, modify behavior and judgment based on previous experiences, and prevent repetition of errors leading to complications. The objective of this study was to determine if M&M conferences can reduce repetitive error making demonstrated by a shift of the incidence of cases presented at M&M by chief complaint (CC) and experience of attendings.

METHODS

All M&M cases from 1/1/2014-12/31/2017 derived from an urban, tertiary referral Emergency Department were reviewed and grouped into 12 different CC categories and by attending years of experience (1-4, 5-9 and 10+). Number and percent of M&M cases by CC and years of attending experience were calculated by year and a chi-squared analysis was performed.

RESULTS

350 M&M cases were presented over the four-year study period. There was a significant difference between CC categories from year-to-year (p < 0.001). Attendings with 1-4 years of experience had the majority of cases (46.3%), while those with 5-9 years had the fewest total cases (15.1%, p < 0.001).

CONCLUSIONS

There was a persistent significant difference across CC categories of M&M cases from year-to-year, with down-trending and up-trending of specific CCs suggesting that M&M presentation may prevent repetitive errors. Newer attendings show increased rates of M&M cases relative to more experienced attendings. There may be a distinctive educational benefit of participation at M&M for attendings with fewer than five years of clinical experience.

Lessons Learned From the Surgical Morbidity and Mortality Conference

OBJECTIVE

The Morbidity and Mortality (M&M) conference is both a quality improvement and an educational conference. We sought to evaluate the educational and quality improvement value of different learners who attend the surgical M&M conference. Furthermore, we sought to evaluate if an educational intervention directed at medical students (MS) would improve their experience at this conference.

DESIGN

Over a 2-month period, we used a third party, real-time audience polling software during 4 M&M conferences using questions concerning medical error, loop closure, learning value, applicability, and professionalism. After baseline data were obtained in Phase 1, MS attended a seminar on the subject of error as part of their orientation. Additionally, to facilitate their preparation, MS were supplied the cases to be presented at that week's conference, a few days before M&M. After this intervention, 3 additional M&M conferences were polled, as described above, as part of Phase 2. Differences between faculty (FAC) and MS experience were assessed by chi-square and ANOVA analyses as appropriate. Study was reviewed and received a waiver from the IRB.

SETTING

Rhode Island Hospital, Providence, Rhode Island, a tertiary care academic teaching hospital of Brown University.

PARTICIPANTS

Audience participants were informed of the voluntary nature of this survey and asked to self-identify as MS, PA/NPs, junior residents, senior residents, or FAC. In phase 1, there were an average of 289 ± 18.7 responses per session, while in phase 2 there were an average of 267 ± 9.29 responses per session.

RESULTS

In Phase 1, when asked to characterize the error as practitioner, system, both practitioner and system or neither, FAC were more likely to assign error as practitioner error than MS (15/38 - 39.5% vs 6/41 - 14.6%, p = 0.021). This trend continued in Phase 2, FAC (19/33 - 57.6%) vs MS (8/29 - 27.6%), p = 0.011. In terms of whether learners felt the conference was useful to their education (5 point scale - strongly agree to strongly disagree) the FAC felt conference more useful than MS (4.0 vs 3.63 p = 0.005). This trend continued even after intervention (4.24 vs 3.71 p < 0.001). The FAC and MS had the same opinion as to the closure of the case being "education at conference," change in policy/procedure, both, neither, no response - average: 75, 3, 9, 6, 7%. Both the FAC and the MS felt the environment was professional (Phase 1: 4.42 v 4.18, p = 0.321)(Phase 2: 4.43 v 4.37, p = 0.1002).

CONCLUSION

Despite an educational intervention, we found FAC and MS maintained very divergent opinions as to what is practitioner error, and system error, and FAC found the M&M discussion more educational than MS. To maximize learning for MS during surgical M&M more interventions are needed.

Electronic Voting to Improve Morbidity and Mortality Conferences

BACKGROUND

It is of major importance in clinical surgery to identify potential patterns and specific causes of complications. Therefore, morbidity and mortality meetings (M&M) are widely used to discuss and evaluate deviations from expected outcomes in order to improve surgical practice. Moreover, M&M represent an important tool for continuous medical education. In this study, we introduced an electronic voting system to assess whether anonymity during M&M could limit potential biases due to hierarchical structures or opinion leaders.

METHODS

This study was conducted in the surgical department of a European tertiary care center. During the study period, electronic voting was applied in 412 M&M cases and compared with a baseline of 330 conventional M&M entries. In this interrupted time series, the educational quality and participant satisfaction of the M&M were assessed using surveys before and after the introduction of electronic voting. The surveys were refined using principle component analysis. In addition, the classification of the cause of the complication was recorded.

RESULTS

The introduction of electronic voting led to a significant increase in perceived educational quality from 2.63 to 3.36 (p < 0.01), and the overall participant satisfaction increased from 2.6 ± 0.9 to 3.7 ± 1.2 (p < 0.01) on a five-point Likert scale. The frequency of voting shifted from "patient's disease" (before 42.9, after 27.6%, p = 0.04) to "misadventure" (before 1.1, after 16.0%, p < 0.01). The voting frequencies for the causes attributed to "management" and "technical" remained constant.

CONCLUSIONS

An electronic voting system in M&M meetings increases perceived educational quality and participant satisfaction.

Implementation status of morbidity and mortality conferences in Swiss hospitals: a national cross-sectional survey study

Objective

To determine the implementation status and current practice of morbidity and mortality conferences (M&MCs) in Switzerland.

Design

A national cross-sectional online survey was conducted in spring 2017. The questionnaire focused on overall goals, structure and procedures of hospital M&MCs. Further topics included satisfaction, perceived effectiveness and support requirements.

Setting

A total of 913 chief physicians of surgery and internal medicine, and specialist fields of obstetrics and gynaecology, anaesthesiology and intensive care from Swiss acute care hospitals were invited to the survey. 321 completed the questionnaire, resulting in a 35.2% response rate.

Participants

Chief or senior physicians in charge of the M&MCs in their department.

Intervention

No intervention

Main Outcome Measures

Numbers and percentages of M&MCs within the surveyed disciplines fulfilling certain characteristics and procedural features.

Results

Among 321 respondents, the majority are conducting M&MCs in their departments. Within and between the medical disciplines considerable heterogeneity was found in structural and procedural features of M&MCs. Only a small part of the reported M&MCs is following a systematic approach and meeting recommended procedural features. Although the respondents are satisfied and perceive the M&MCs as an efficient tool, they agree that there is a need for professionalization and standardization.

Conclusion

M&MCs are widely used to promote medical education, patient safety and quality improvements. However, the term M&MC seems to cover different types of meetings. Although the overall goals are similar, various types of M&MCs are used in practice and different objectives are pursued. Tools such as checklists, guidelines and templates are considered helpful.

[Morbidity and mortality conferences in Lower Saxony: Implementation status and further development needs]

BACKGROUND

Morbidity and mortality conferences (M&MC) are a tool to foster individual and organizational learning in hospitals, and they are important to improve patient safety. So far, no data has been available about the implementation of M&MC in Lower Saxony and the characteristics of M&MCs. The aim of this study was to assess the status quo of M&MC in Lower Saxony and to identify the potential for improvement.

METHODS

A cross-sectional survey study was conducted among chief physicians in surgery, internal medicine, anesthesiology/intensive care, gynecology/obstetrics and pediatrics (response rate: 50 %).

RESULTS

Apart from technical topics (37 %), the main issues addressed are process (92 %) and teamwork (64 %) issues. The results also show a strong heterogeneity in terms of structures and processes of implemented M&MC in Lower Saxony. Despite a high level of satisfaction (85 %) and perceived effectiveness (93 %), most participants see potential for improvement of "their" M&MC (58 %).

CONCLUSION

Chief physicians in Lower Saxony report both a high level of acceptance and the need for further improvement of the M&MCs, which represents good preconditions for further development towards effective M&MCs.

Toward Best Practices for Surgical Morbidity and Mortality Conferences: A Mixed Methods Study

OBJECTIVE

To assess formats for surgical morbidity and mortality conferences (M&M) for strengths and challenges.

DESIGN

A mixed methods approach with local observations to assess key domains of M&M practice (i.e., goals, structure, and process/content) and surveys to assess participants' expectations and experiences.

SETTING

Surgical departments of two teaching hospitals (Boston, USA and Leiden, Netherlands).

PARTICIPANTS

Participants of surgical M&M, including attending surgeons, residents, physician assistants, and medical students (total n = 135).

RESULTS

Surgical M&M practices at both hospitals had education as its overarching goal, but varied in structure and process/content. Expectations were similar at both sites with ≥80% of participants (n = 90; 67% response) expecting M&M to be focused on education as well as quality improvement (QI), blame-free, mandatory for both residents and attendings, and to lead to changes in clinical practice. However, compared to expectations, significantly fewer participants at both sites experienced: a QI focus (both p < 0.001); mandatory faculty attendance (p = 0.004; p < 0.001) and changes to practice (both p < 0.001). In comparison, at the site where an active moderator and QI committee are present, respondents seemed more positive about experiencing a QI focus (73% vs 30%) and changes to practice (44% vs 16%).

CONCLUSION

Despite variation in M&M practice, the same (unmet) expectations existed at both hospitals, indicating that certain challenges may be more universal. M&M was reported to be well-focused on education, and certain aspects (e.g., active moderator and QI committee) seemed beneficial, but expectations were not met for the conference's focus and function for QI. Greater exchange of "best practices" for M&M may enhance the conference's value for improving surgical care.

Barriers and facilitators to learn and improve through morbidity and mortality conferences: a qualitative study

OBJECTIVES

To explore barriers and facilitators to successful morbidity and mortality conferences (M&M), driving learning and improvement.

DESIGN

This is a qualitative study with semistructured interviews. Inductive, thematic content analysis was used to identify barriers and facilitators, which were structured across a pre-existing framework for change in healthcare.

SETTING

Dutch academic surgical department with a long tradition of M&M.

PARTICIPANTS

An interview sample of surgeons, residents and physician assistants (n=12).

RESULTS

A total of 57 barriers and facilitators to successful M&M, covering 18 themes, varying from 'case type' to 'leadership', were perceived by surgical staff. While some factors related to M&M organisation, others concerned individual or social aspects. Eight factors, of which four were at the social level, had simultaneous positive and negative effects (eg, 'hierarchy' and 'team spirit'). Mediating pathways for M&M success were found to relate to available information, staff motivation and realisation processes.

CONCLUSIONS

This study provides leads for improvement of M&M practice, as well as for further research on key elements of successful M&M. Various factors were perceived to affect M&M success, of which many were individual and social rather than organisational factors, affecting information and realisation processes but also staff motivation. Based on these findings, practical recommendations were formulated to guide efforts towards best practices for M&M.

Effects of efforts to optimise morbidity and mortality rounds to serve contemporary quality improvement and educational goals: a systematic review

Background

The quality and safety movement has reinvigorated interest in optimising morbidity and mortality (M&M) rounds. We performed a systematic review to identify effective means of updating M&M rounds to (1) identify and address quality and safety issues, and (2) address contemporary educational goals.

Methods

Relevant databases (Medline, Embase, PubMed, Education Resource Information Centre, Cumulative Index to Nursing and Allied Health Literature, Healthstar, and Global Health) were searched to identify primary sources. Studies were included if they (1) investigated an intervention applied to M&M rounds, (2) reported outcomes relevant to the identification of quality and safety issues, or educational outcomes relevant to quality improvement (QI), patient safety or general medical education and (3) included a control group. Study quality was assessed using the Medical Education Research Study Quality Instrument and Newcastle-Ottawa Scale-Education instruments. Given the heterogeneity of interventions and outcome measures, results were analysed thematically.

Results

The final analysis included 19 studies. We identified multiple effective strategies (updating objectives, standardising elements of rounds and attaching rounds to a formal quality committee) to optimise M&M rounds for a QI/safety purpose. These efforts were associated with successful integration of quality and safety content into rounds, and increased implementation of QI interventions. Consistent effects on educational outcomes were difficult to identify, likely due to the use of methodologies ill-fitted for educational research.

Conclusions

These results are encouraging for those seeking to optimise the quality and safety mission of M&M rounds. However, the inability to identify consistent educational effects suggests the investigation of M&M rounds could benefit from additional methodologies (qualitative, mixed methods) in order to understand the complex mechanisms driving learning at M&M rounds.

Introducing a Morbidity and Mortality Conference in Rwanda

OBJECTIVES

To assess the structure, format, and educational features of a morbidity and mortality (M&M) conference in Rwanda. To determine factors associated with adverse events and to define opportunities for improvement.

DESIGN

Retrospective, descriptive study of all cases presented at a surgical M&M conference over a 1-year period. Cases were reviewed for factors associated with adverse events and opportunities for improvement. Factors were characterized as delays in presentation, delays in diagnosis, delays in the operating room, errors in judgment, technical errors, advanced disease, and missing resources or malnutrition. Opportunities for improvement were categorized at the physician or hospital level.

SETTING

University Teaching Hospital of Kigali, a tertiary referral hospital in Rwanda.

PARTICIPANTS

Cases presented at the surgical M&M conference over a 1-year period.

RESULTS

Over a 1-year period, there were a total of 2231 operations with 131 in-hospital mortalities. There were 62 patients discussed at M&M conference. Of those discussed, there were 34 (55%) in-hospital deaths and 32 (52%) unplanned reoperations. Common diagnostic categories included 30 (48%) gastrointestinal, 15 (24%) trauma, and 10 (16%) neoplasm. Delays were commonly cited factors affecting outcomes. There were 22 (35%) delays in presentation, 23 (37%) delays in diagnosis or management, and 20 (32%) delays to the operating room. Errors in judgment occurred in 15 (24%) cases and technical errors occurred in 18 (29%) cases. Twenty-three (37%) patients had a critical resource missing and 17 (27%) patients had advanced disease. Malnutrition was associated with 11 (18%) adverse events. Participants identified opportunities for improvement in 48 (77%) cases.

CONCLUSION

M&M conference can be used in a low-resource setting as an educational tool to address core competencies of practice-based learning and improvement and systems-based practice. It can define factors associated with surgical adverse events and opportunities for improvement at the physician and hospital levels.

From Morbidity and Mortality to Quality Improvement: Effects of a Structured and Interactive Otolaryngology Conference

Objective

Measure the effects of a structured morbidity and mortality conference format on the attitudes of resident and faculty participants.

Study Design

Prospective cohort study.

Setting

Otorhinolaryngology–head and neck surgery residency training program.

Subjects and Methods

Two changes were implemented to the structure of our morbidity and mortality conference: (1) we adopted a recently described presentation framework called situation-background-assessment-recommendation and (2) appointed a faculty moderator to lead the conference. Surveys were distributed to residents and faculty before and after these modifications were implemented to measure changes in attitude of conference attendees.

Results

After implementing the above changes to the morbidity and mortality conference, participant engagement increased from “moderately engaged” to “extremely engaged” (P < .01). Among both faculty and residents, the perceived educational value of conference also improved from “moderately educational” to “extremely educational” (P < .01). Finally in the attending cohort, the impact on future patient care increased from “no change” to “greatly enhanced” (P < .01).

Conclusion

By implementing the situation-background-assessment-recommendation framework and appointing a faculty moderator to morbidity and mortality conference, participants reported significantly enhanced engagement during the conference, increased educational value of the session, and a positive impact on future patient care.

Morbidity and Mortality Conferences: A Narrative Review of Strategies to Prioritize Quality Improvement

BACKGROUND

The morbidity and mortality conference (MMC) provides a valuable opportunity to review patient care processes and safety concerns, aligning with a growing quality improvement (QI) mandate. Yet the structure, processes, and aims of many MMCs are often ill-defined. This review summarizes strategies employed by medical, surgical, and critical care departments in the development of patient safety-centered MMCs.

METHODS

A structured narrative review of literature was conducted using combinations of the search terms "morbidity and mortality conference(s)," "morbidity and mortality meetings," or "morbidity and mortality round(s)." The titles and abstracts of 250 returned articles were screened; 76 articles were reviewed in full, with 32 meeting the full inclusion criteria.

RESULTS

The literature review elicited a number of methods used by medical, surgical, and critical care MMCs to emphasize QI and patient safety outcomes. A list of actionable changes made in each article was compiled. Five themes common to QI-centered MMCs were identified: (1) defining the role of the MMC, (2) involving stakeholders, (3) detecting and selecting appropriate cases for presentation, (4) structuring goal-directed discussion, and (5) forming recommendations and assigning follow-up. Innovative methods to pair adverse event screening with MMCs were superior to nonstructured voluntary reporting and case selection for overall morbidity detection. Structured case review, discussion, and follow-up were more likely to lead to implementing systems-based change, and interdisciplinary MMCs were associated with a greater likelihood of forming an action item.

CONCLUSION

The modern patient safety-centered MMC shares common themes of practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and a culture of safety.

Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: a survey of participants' perceptions

Background

Evidence for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. The aim of this survey was to assess the opinion of participants concerning the benefits and the functioning of morbidity and mortality conferences, according to their organizational characteristics.

Methods

We conducted a survey of professionals involved in a morbidity and mortality conference using a self-administered questionnaire in three French teaching hospitals in 2012. The questionnaire focused on the functioning of morbidity and mortality conferences, the perceived benefits, the motivations of participants, and how morbidity and mortality conferences could be improved. The perception of participants was analysed according to the characteristics of morbidity and mortality conferences.

Results

A total of 698 participants in 54 morbidity and mortality conferences completed the questionnaire. Most of them (91 %) were satisfied with how the morbidity and mortality conference they attended was conducted. The improvements in healthcare quality and patient safety were the main benefits perceived by participants. Effectiveness in improving safety was mainly perceived when cases were thoroughly analysed (adjusted odds ratio [a0R] =2.31 [1.14–4.66]). The existence of a written charter (p = 0.05), the use of a standardized case presentation (p = 0.049), and prior dissemination of the meeting agenda (p = 0.02) were also associated with the perception of morbidity and mortality conference effectiveness. The development and achievement of improvement initiatives were associated with morbidity and mortality conferences perceived as being more effective (p < 0.01). Participants suggested improving the attendance of medical and paramedical professionals to enhance the effectiveness of morbidity and mortality conferences.

Conclusions

Morbidity and mortality conferences were positively perceived. These results suggest that a structured framework and thoroughly analyzing cases improve their effectiveness.

Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study

Background

The aim of this study was to identify the characteristics of morbidity and mortality conferences (MMCs) associated with the implementation of patient health-care quality and safety improvement initiatives.

Methods

We conducted an observational study of MMCs and followed up improvement initiatives for 1 year. Data on MMC baseline characteristics were abstracted using document analysis and observation of a meeting in three university hospitals in France (Grenoble, Nice, and Cochin [Paris] hospitals). Fifty-nine MMCs were included in medical (n = 24), surgical (n = 21), and anesthesiology and/or intensive care (n = 14) departments. An effectiveness index was computed by summing a composite score for each initiative pertaining to the MMC.

Results

Overall, 282 initiatives were identified in 42 MMCs. During the follow-up period, 215 initiatives (76 %) were totally or partially implemented and the impact was evaluated for 73 (26 %). An effectiveness index higher than the median (i.e., ≥10) was associated with a standardized presentation of cases (81 % versus 29 %, p <0.001), recording of improvement initiatives (94 versus 57, p = 0.001), the existence of an annual activity report (94 % versus 68 %, p = 0.01), the prior dissemination of a meeting agenda (71 % versus 36 %, p = 0.007), longer meeting duration (109 versus 80 min, p = 0.005), anesthesiology and/or intensive care specialty (39 % versus 7 %, p = 0.02), a theme-focused MMC (29 % versus 4 %, p = 0.01), and a thorough analysis of failures (58 % versus 25 %, p = 0.01).

Conclusions

This study suggests that the implementation of improvement initiatives relates to MCC characteristics. Recommendations for developing more effective patient safety-oriented MMCs can be proposed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1279-8) contains supplementary material, which is available to authorized users.

At the Crossroad with Morbidity and Mortality Conferences: Lessons Learned through a Narrative Systematic Review

Objective. To determine the process and structure of Morbidity and Mortality Conference (MMC) and to provide guidelines for conducting MMC. Methods. Using a narrative systematic review methodology, literature search was performed from January 1, 1950, to October 2, 2012. Original articles in adult population were included. MMC process and structure, as well as baseline study demographics, main results, and conclusions, were collected. Results. 38 articles were included. 10/38 (26%) pertained to medical subspecialties and 25/38 (66%) to surgical subspecialties. 15/38 (40%) were prospective, 14/38 (37%) retrospective, 7/38 (18%) interventional, and 2/38 (5%) cross-sectional. The goals were quality improvement and education. Of the 10 medical articles, MMC were conducted monthly 60% of the time. Cases discussed included complications (60%), deaths (30%), educational values (30%), and system issues (40%). Recommendations for improvements were made frequently (90%). Of the 25 articles in surgery, MMCs were weekly (60% of the time). Cases covered mainly complications (72%) and death (52%), with fewer cases dedicated to education (12%). System issues and recommendations were less commonly reported. Conclusion. Fundamental differences existed in medical versus surgical departments in conducting MMC, although the goals remained similar. We provide a schematic guideline for MMC through a summary of existing literature.

The Utility of the Matrix Format for Surgical Morbidity and Mortality Conference

With the limitations posed by increasing work hour restrictions, surgical residency programs are focusing more on maximizing the educational benefit of their conferences. The Morbidity and Mortality (M&M) conference serves as a forum to discuss adverse events and patient care improvement using evidence-based medicine. The matrix format (MF) is an enhancement to the traditional format (TF), focusing on the case selection process and a postconference newsletter reiterating the relevant literature review and discussion points. Our institution adopted the MF to evaluate both its short- and long-term educational values. Surveys were distributed to residents and faculty within the Department of General Surgery to assess their interest and satisfaction, perception of educational value, and efficiency with the MF compared with the TF. Responses were obtained from 22/22 (100%) residents for the TF and 11/23 (48%) for the MF. Faculty responses were 19/19 (100%) and 9/16 (56%), respectively. Reasons for an overall decreased response with the MF were not investigated further, as participation was strictly voluntary. Our results confirmed an overall approval of the MF by both residents and faculty. Faculty reported an improved efficiency of the conference ( P < 0.039), encompassing improved content and presentation quality. Residents reported an improved overall interest and satisfaction with the MF ( P < 0.001) as well as an improvement in the educational value ( P < 0.007). Residents spent less time preparing presentations and reported learning greater educational benefit to the conference when preparing their own presentations ( P < 0.001). In conclusion, the MF resulted in a greater overall satisfaction for residents and attending surgeons with an increased investment by the audience and overall improvement in perceived educational benefit.

A national questionnaire survey of consultants and middle grade doctors' perception of foundation doctors in obstetrics and gynaecology in the United Kingdom

AIM

The aim of this study was to compare foundation doctors in obstetrics and gynaecology to the former grade of senior house officer, as perceived by their consultant and middle grade colleagues.

METHODS

A self-construct questionnaire was sent to College District Tutors in obstetrics and gynaecology in all hospitals in the United Kingdom, for circulation to all consultants and middle grade doctors in obstetrics and gynaecology in their departments.

RESULTS

A total of 155 questionnaires were returned, 143 completed and 12 indicating not having foundation doctors. Whilst about 50 % of respondents ranked the competencies of foundation year doctors as similar to that of the former senior house officer grade, the ratings were down in areas specific to obstetrics and gynaecology, such as seeing new patients in antenatal clinic, and up in general terms such as communication. General comments highlighted differences in ability and role and suggested longer attachments and less frequent changes in training structure.

CONCLUSIONS

The study highlighted the need to focus on teaching generic skills in shorter durations and reflection on whole-patient management, which are relevant to all specialities. It underlined the impact of more frequent change of doctors on service delivery and recommended having a further look at foundation training programme before making any future changes.

Improving cancer patient care with combined medication error reviews and morbidity and mortality conferences

BACKGROUND

To reduce the occurrence of medication errors, a systemic approach was developed combining anti-neoplastic medication error reviews and morbidity and mortality conferences (M&MCs). We report the first experience of implementing this strategy in oncology.

METHODS

The case reports submitted to combined reviews were prepared by physicians and pharmacists, and medication error(s) were described and chronological and root-cause analyses were performed.

RESULTS

Ten combined reviews were conducted, which involved the departments of haematology, medical oncology, pneumology, gastroenterology and clinical oncology pharmacy. A total of 91 errors were analysed, of which 3 had reached the patient. Thirty-four corrective actions were proposed; 53% consisted of changes in practice, 35% in procedural reminders and 12% in on-ward education sessions.

CONCLUSIONS

The combination of medication error reviews and M&MCs appears to be an efficient means of improving cancer patient safety and personnel proficiency. This multidisciplinary work is indispensable to improve future patient management through the critical analysis of past medical errors.

Informal learning from error in hospitals: what do we learn, how do we learn and how can informal learning be enhanced? A narrative review

Learning from error is not just an individual endeavour. Organisations also learn from error. Hospitals provide many learning opportunities, which can be formal or informal. Informal learning from error in hospitals has not been researched in much depth so this narrative review focuses on five learning opportunities: morbidity and mortality conferences, incident reporting systems, patient claims and complaints, chart review and prospective risk analysis. For each of them we describe: (1) what can be learnt, categorised according to the seven CanMEDS competencies; (2) how it is possible to learn from them, analysed against a model of informal and incidental learning; and (3) how this learning can be enhanced. All CanMEDS competencies could be enhanced, but there was a particular focus on the roles of medical expert and manager. Informal learning occurred mostly through reflection and action and was often linked to the learning of others. Most important to enhance informal learning from these learning opportunities was the realisation of a climate of collaboration and trust. Possible new directions for future research on informal learning from error in hospitals might focus on ways to measure informal learning and the balance between formal and informal learning. Finally, 12 recommendations about how hospitals could enhance informal learning within their organisation are given.

The reflective statement: a new tool to assess resident learning

PURPOSE

Continued assessment and redesign of the curriculum is essential for optimal surgical education. For the last 3 y, we have asked the residents to reflect on the previous week and describe "the best thing" they learned. We hypothesize that this statement could be used to assess the weaknesses or strengths of our curriculum.

METHODS

Starting in 2007, residents filled out surveys approximately 4 times/y at the start of a mandatory conference. They were asked to describe the "best thing" they learned that week, where it was learned, and who taught it. Residents were not asked to classify the item learned by core competency (communication, knowledge, patient care, practice-based learning, professionalism, and systems-based practice). This categorization into core competencies was done as part of our study design. Attending, fellow, resident, or other were used as groups designating who taught each item. Where the item was learned was fit into either clinic, conference, operating room (OR), wards, or self. The impact of postgraduate year (PGY) level on learning was also assessed. χ(2) analysis was used to compare groups.

RESULTS

During the study period, 304 surveys were completed and returned by 65 residents. The majority of responses came from PGY 1 residents (134, 43%). Patient care and knowledge were the most common core competencies learned. As PGY level increased, learning of professionalism (P = 0.035) increased. A majority of learning was experiential (wards and OR, P < 0.0125). Self-learning and learning in clinic was a minor component of learning (P < 0.0125). Learning on wards (P < 0.001) decreased as residents progressed and learning from the OR (P = 0.002) had the opposite trend.

CONCLUSIONS

Patient care and knowledge are the most frequently cited competencies learned by the residents. Self-learning is not a significant source of learning, and the majority of the learning is experiential. It is not known if this was a sign that there was a lack of self-directed learning or that self-directed learning was not an efficient method of learning. In addition, each PGY level learns differently (teacher and location of learning), perhaps reflecting the different needs and/or structure of each PGY. We believe the reflective statement has been and will be a useful tool to assess our curriculum.