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

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.

Goals of the Morbidity and Mortality meeting in acute care: A scoping review

OBJECTIVE

The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting.

REVIEW METHODS USED

The study utilised scoping review methodology.

DATA SOURCES

Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers.

REVIEW METHODS

Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories.

RESULTS

Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support.

CONCLUSIONS

There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

Implementation of morbidity and mortality conference in a community hospital NICU and narrative review

Background

The process of morbidity and mortality review (MMR) is recognized as an essential component of quality improvement, patient safety, attitudes towards patient safety, and continuing education. Despite the common use of MMR for all disciplines of medical care, recommendations have not been published regarding the implementation of MMR in a community hospital setting in the United States.

Objectives

Review the literature on MMR conferences. Describe the implementation of an MMR conference in a community hospital neonatal intensive care unit (NICU).

Conclusions

The establishment of a case overview method of MMR is feasible for a community hospital NICU. It increases staff and physician group awareness and education over common and complex mortality and morbidity etiologies, improves staff participation with unit management, links case presentation with open discussion and action items, and identifies opportunities for systemic changes to improve patient care.

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.

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.

A Novel System to Improve Case Capture for Surgery Morbidity and Mortality Conference

INTRODUCTION

Complications are often under-reported at surgical morbidity and mortality (M&M) conferences due to the sole reliance on voluntary case submission. While most institutions have databases used for targeted initiatives in quality improvement, these are not routinely used for M&M. We aimed to increase case capture for M&M conferences by developing a novel system that augments the existing case submission system with cases representing complications from quality improvement databases and the electronic health record (EHR).

METHODS

We developed and implemented a novel system for increasing the capture rate of complications for M&M conferences by developing custom software that combines data from the following sources: an existing voluntary case submission system for M&M, local quality databases-National Surgical Quality Improvement Program and Vizient, and an EHR-based case capture tool. We evaluated this system on a retrospective cohort of all postoperative complications at a single center in a 32-mo period and in a prospective cohort over a 4-mo period after system implementation.

RESULTS

In the retrospective cohort, we identified 433 complications among all data sources. Inclusion of the new system introduced 280 new potential cases for M&M review over the 32-mo period. After implementation, the system provided 31% of cases presented at M&M conference that would have otherwise been omitted.

CONCLUSIONS

A novel system that includes complications identified in the EHR and quality improvement databases increased the case capture volume for surgical M&M conference, which provides an objective case referral system that can identify complementary quality improvement opportunities.

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.

Parent Participation in Morbidity and Mortality Review: Parent and Physician Perspectives

This study examined Morbidity and Mortality (M&M) review practices and perspectives of physicians and parents regarding parent participation in M&M review. Surveys were distributed to parents of children with a prior hospitalization for congenital heart disease (CHD) and physicians caring for pediatric CHD patients. Response distributions and Fisher’s exact tests were performed to compare parent and physician responses. Qualitative survey data were thematically analyzed. Ninety-two parent and 36 physician surveys were analyzed. Physicians reported parent input or participation was rarely sought in M&M review. Parents with direct experience of adverse events or death of their child reported providers discussed events with them in a timely manner and answered their questions; however, nearly half wished their healthcare team had done something differently during the disclosure. There was no statistical difference between groups regarding transparency ( P = .37, .79); however, there was a significant difference in perspectives regarding parental involvement in the M&M review ( P < .001). Common themes important to parents which emerged from the qualitative analysis were being adequately informed, feeling their perspectives were acknowledged and respected, having attentive and empathetic providers, and receiving consistent messaging. Although rarely included in current practice, parent participation in M&M could offer unique insight and increase accountability to proposed change elucidated by M&M review.

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.

What are the participants' perspective and the system-based impact of a standardized, inter-professional morbidity/mortality-conferences in a children's hospital?

Background

Morbidity and mortality conferences (MMC) are well established but little data exists on inter-professional aspects, system-based outcomes and characteristics in pediatric departments. Our study aim was to analyze the system-based impact and to assess participant's perspectives on standardized, inter-professional MMCs in a children's hospital.

Methods

In a prospective observational analysis the inter-professional MMCs held at a tertiary teaching children's hospital in Switzerland were analyzed for (I) resulting clinical consequences and (II) participants perception on format, usefulness and no-blame atmosphere.

Results

Eighteen MMC, discussing 29 cases were analyzed. Twenty-seven clinical errors/problems were identified and 17 clinical recommendations were developed: ten new or changed clinical guidelines, two new therapeutic alternatives, three new teaching activities, and two guidelines on specific diagnostics. Altogether, the 466 participants evaluated the conferences favorably. Little differences were seen in the evaluations of physicians of different disciplines or seniority but non-physicians scored all questions lower than physicians. Overall, three quarters of the participants felt that there was a no-blame culture during the conferences but results varied depending on the cases discussed.

Conclusions

An inter-professional MMC can have relevant impact on clinical practice and affect system-based changes. Inter-professional conferences are profitable for all participants but evaluated differently according to profession. A standardized format and the presence of a moderator are helpful, but not a guarantee for a no-blame culture. Highly emotional cases are a risk factor to relapse to "blame and shame". A time gap between the event and the MMC may have a beneficial effect.

Keywords

Inter-professional communication; inter-professional health care; learning from failure; morbidity and mortality conference (MMC); patient safety; psychological safety.

The Morbidity & Mortality Assessment Tool (MMAT): Design and Proof of Concept

BACKGROUND

Morbidity and Mortality Conference (MMC) is a traditional quality assessment tool among surgical residencies to evaluate complications within their care and to integrate and educate best practices. Unfortunately, it is difficult to validate and measure loop closure as a result of MMC. This may result in repeating past mistakes or worse, becoming a meeting of anecdotal experiences. The goal of this study is to present results from a morbidity and mortality assessment tool (MMAT) which provides a means of measuring and tracking factors related to those surgical complications discussed within the MMC.

MATERIALS AND METHODS

Three years of MMC presentations were organized into a database and further divided and organized into variables which included case by the class year of the presenting resident, service line, month the case was presented, and potential contributing factors. Contributing factors considered for each case were categorized as: Systems-Based, Direct Patient Care, and Interpersonal Communication. Contributing factors were assigned to cases by a review committee consisting of residents and faculty members.

RESULTS

The lack of knowledge, technical error, lack of experience, lack of supervision, failure to communicate with team members were present in greater than 10% of the presented cases. There was a "July Effect" in the Trauma service, where there was a statistically significant difference between the percentage of cases presented that involved Failure to Communicate errors when compared with the remainder of the year.

CONCLUSIONS

MMAT allows longitudinal collection of data from each MMC to recognize patterns that facilitate improvements in systems of care and institutional memory.

A Survey of the Surgical Morbidity and Mortality Conference in the United States and Canada: A Dying Tradition or the Key to Modern Quality Improvement?

OBJECTIVE

We seek to identify the current role and practices of the surgery morbidity and mortality (M&M) conference in academic surgery departments in the United States and Canada.

DESIGN, SETTING, AND PARTICIPANTS

All members of the Society of Surgical Chairs, a program of the American College of Surgeons, were e-mailed an IRB-approved 28-question electronic survey in fall 2017. Up to 3 reminders were sent.

RESULTS

Responses from 129/186 (69%) departments of surgery were received. Nearly all departments (96%) continue to have a departmental M&M conference. The M&M conference is typically weekly (93%), between 7 and 9 AM (80%), on weekdays during which there are no scheduled elective operations (84%). Attendance is mandatory for residents (98%), but required for faculty in only 49% of departments. Fewer than half of all departments (44%) have written guidelines as to which complications should be reported to M&M. Most conferences are prepared case presentations (89%), but may include unprepared discussions (17%), case-based educational presentations (30%), or a combination (28%). The most common classification category was by root case of the error (60%) and preventability (58%). Most departments keep electronic and/or physical M&M reports, while 21% maintain a relational database and 25% do not retain records. While almost all (96%) departments reported participating in at least one national quality improvement program, these are not often linked to the M&M process.

CONCLUSIONS

M&M is predominantly seen as an educational conference based on a few select cases. Departmental quality is monitored with hospital-driven or national quality improvement efforts. Integration of hospital-based quality metric programs with surgery M&M conference is uncommon and represents an opportunity for hospital-department collaboration.

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement

After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

Openness to new perspectives created by patient participation at the morbidity and mortality meeting

OBJECTIVES

Morbidity and mortality meetings (M&MMs) at surgical departments may improve when patients participate, leading to different learning points. A gynecological oncology department invited patients to join their M&MMs. The practical constraints and experiences important from the perspective of patients and their healthcare professionals were evaluated.

METHODS

Semi-structured interviews were conducted with patients and professionals who attended M&MMs at a gynecological oncology department between 2016 and 2018. The interviews were transcribed and coded and thematic content analysis was performed.

RESULTS

Eight patients and 17 healthcare professionals participated. Eleven themes related to interpersonal dynamics. The five shared themes are: patient-doctor relationship, language, openness of communication, learning and personal impact. All participants suggested maintaining the new practical design of the M&MMs.

CONCLUSIONS

Patients and healthcare professionals valued patient participation in the M&MMs. Patient participation is possible when professionals are open to discussing and learning from adverse events (AEs). In this setting, patients feel that they are taken seriously and gain a better understanding of the course of an AE.

PRACTICE IMPLICATIONS

Involving patients in M&MMs led to new insights, better understanding, and improved processing of AEs. Collaborating with patients and using their feedback seems to be effective when developing innovations in healthcare.

Taking Morbidity and Mortality Conferences to a Next Level: The Resilience Engineering Concept

OBJECTIVE

To explore possibilities to improve morbidity and mortality conferences using advancing insights in safety science.

SUMMARY BACKGROUND DATA

Mortality and Morbidity conferences (M&M) are the golden practice for case-based learning. While learning from complications is useful, M&M does not meet expectations for system-wide improvement. Resilience engineering principles may be used to improve M&M.

METHODS

After a review of the shortcomings of traditional M&M, resilience engineering principles are explored as a new way to evaluate performance. This led to the development of a new M&M format that also reviews successful outcomes, rather than only complications. This "quality assessment meeting" (QAM) is presented and the first experiences are evaluated using local observations and a survey.

RESULTS

During the QAM teams evaluate all discharged patients, addressing team resilience in terms of surgeons' ability to respond to irregularities and to monitor and learn from experiences. The meeting was feasible to implement and well received by the surgical team. Observations reveal that reflection on both complicated and uncomplicated cases strengthened team morale but also triggered reflection on the entire clinical course. The QAM serves as a tool to identify how adapting behavior led to success despite challenging conditions, so that this resilient performance can be supported.

CONCLUSIONS

The resilience engineering concept can be used to adjust M&M, in which learning is focused not only on complications but also on how successful outcomes were achieved despite ever-present challenges. This reveals the actual ratio between successful and unsuccessful outcomes, allowing to learn from both to reinforce safety-enhancing behavior.

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.

Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference

OBJECTIVES

We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors.

METHODS

We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test.

RESULTS

Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous.

CONCLUSIONS

We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

More than experience: a post-task reflection intervention among team members enhances performance in student teams confronted with a simulated resuscitation task-a prospective randomised trial

Background

Teams that regularly step back from action and deliberately reflect on their performance and strategies show higher performance. Ad hoc emergency teams with changing team composition cannot develop such habits but may engage in short postaction reflection to discuss shortcomings of past performance and potential adaptations of their strategies for future similar tasks. This study aimed to test the effect of a short postaction self-led reflective team briefing on resuscitation performance in a simulator setting in terms of three performance parameters: hands-on time, coordination between chest compression and ventilation, and defibrillation.

Methods

We performed a randomised controlled trial including 56 ad hoc formed teams of three fourth-year medical students each. All groups performed a resuscitation task, followed by a self-guided reflective briefing, based on a general instruction (n=28 teams), or an unrelated discussion session (control condition; n=29), followed by a second resuscitation task in the same team composition.

Results

Adjusted for performance in the first task, teams in the reflection condition showed higher performance gain in the second resuscitation than teams in the control condition (6.21 percentage points (95% CI 1.31 to 11.10, p<0.001)) for basic hands-on performance; 15.0 percentage points (95% CI 2 to 28, p<0.001) for coordinative performance but non-significantly lower performance for defibrillation (-9%, 95% CI -27% to -9%, p=0.312).

Conclusion

Even very short self-led postaction reflective briefings enhance basic resuscitation performance in ad hoc groups but may not influence more complex aspects of the task. We recommend including short self-led team debriefings as part of simulator training.

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.

Surgeon-Reported Complications vs AHRQ Patient Safety Indicators: A Comparison of Two Approaches to Identifying Adverse Events

BACKGROUND

Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap.

STUDY DESIGN

This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process.

RESULTS

Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n = 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes.

CONCLUSIONS

Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

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.