Envisioning the Future Morbidity and Mortality Conference: A Vehicle for Systems Change

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

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

Organizational Learning in the Morbidity and Mortality Conference

INTRODUCTION

The focus of morbidity and mortality conferences (M&MCs) has shifted to emphasize quality improvement and systems-level care. However, quality improvement initiatives targeting systems-level errors are challenged by learning in M&MCs, which occurs at the individual attendee level and not at the organizational level. Here, we aimed to describe how organizational learning in M&MCs is optimized by particular organizational and team cultures.

METHODS

A prospective, multiple-case study design was used. Using purposive sampling, three cases covering different medical/surgical specialties in North America were chosen. Data collection included direct observations of the M&MC, semistructured interviews with key M&MC members, and documentary information.

RESULTS

The role of the M&MC in all cases integrated two key concepts: recognition of system-wide trends and learning from error, at an organizational and team level. All cases provided evidence of double-loop learning and used organizational memory strategies to ensure knowledge was retained within the organization. A patient safety culture was linked to the promotion of open communication, fostering learning from adverse events.

CONCLUSION

This study describes three cases of systems-oriented M&MCs that reflected elements of organizational learning theory. The M&MC can therefore provide a context for organizational learning, allowing optimal learning from adverse events.

Diagnostic quality model (DQM): an integrated framework for the assessment of diagnostic quality when using AI/ML

BACKGROUND

Laboratory medicine has reached the era where promises of artificial intelligence and machine learning (AI/ML) seem palpable. Currently, the primary responsibility for risk-benefit assessment in clinical practice resides with the medical director. Unfortunately, there is no tool or concept that enables diagnostic quality assessment for the various potential AI/ML applications. Specifically, we noted that an operational definition of laboratory diagnostic quality - for the specific purpose of assessing AI/ML improvements - is currently missing.

METHODS

A session at the 3rd Strategic Conference of the European Federation of Laboratory Medicine in 2022 on "AI in the Laboratory of the Future" prompted an expert roundtable discussion. Here we present a conceptual diagnostic quality framework for the specific purpose of assessing AI/ML implementations.

RESULTS

The presented framework is termed diagnostic quality model (DQM) and distinguishes AI/ML improvements at the test, procedure, laboratory, or healthcare ecosystem level. The operational definition illustrates the nested relationship among these levels. The model can help to define relevant objectives for implementation and how levels come together to form coherent diagnostics. The affected levels are referred to as scope and we provide a rubric to quantify AI/ML improvements while complying with existing, mandated regulatory standards. We present 4 relevant clinical scenarios including multi-modal diagnostics and compare the model to existing quality management systems.

CONCLUSIONS

A diagnostic quality model is essential to navigate the complexities of clinical AI/ML implementations. The presented diagnostic quality framework can help to specify and communicate the key implications of AI/ML solutions in laboratory diagnostics.

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.

A Resident Morbidity and Mortality Conference Curriculum to Teach Identification of Cognitive Biases, Errors, and Debiasing Strategies

INTRODUCTION

The morbidity and mortality (M&M) conference has long been a part of the education of residents of all specialties in the United States, yet its structure is variable across training programs. Recent literature has described the use of M&M as a forum for education in quality improvement methodology; however, a structure focusing on education in cognitive biases and errors has not been previously described in MedEdPORTAL.

METHODS

This structured M&M conference series called upon resident presenters and peers in the audience to examine cognitive biases and errors involved in specific patient cases. Associated materials included preparatory guidelines provided to faculty advisors and resident presenters, a presentation template used during the introductory session, and a handout used during the discussion portions of presentations.

RESULTS

During the 2019-2020 academic year, a total of 24 PGY 2 pediatrics residents presented M&M cases. They identified a mean of 3.7 (SD = 1.9) cognitive biases and/or errors per case and a mean of 1.7 (SD = 0.7) debiasing strategies per case. Peers in the audience were also successful in identifying potential biases and errors at play during presentations.

DISCUSSION

We found that through this M&M conference structure, residents were able to demonstrate the ability to identify cognitive errors and biases both within themselves and in peers. This provided an effective forum for the identification and discussion of debiasing strategies, even when the series was forced to transition to a virtual format due to the COVID-19 pandemic.

Changing safety culture

Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

The Diagnostic Error Index: A Quality Improvement Initiative to Identify and Measure Diagnostic Errors

OBJECTIVE

To develop a diagnostic error index (DEI) aimed at providing a practical method to identify and measure serious diagnostic errors.

STUDY DESIGN

A quality improvement (QI) study at a quaternary pediatric medical center. Five well-defined domains identified cases of potential diagnostic errors. Identified cases underwent an adjudication process by a multidisciplinary QI team to determine if a diagnostic error occurred. Confirmed diagnostic errors were then aggregated on the DEI. The primary outcome measure was the number of monthly diagnostic errors.

RESULTS

From January 2017 through June 2019, 105 cases of diagnostic error were identified. Morbidity and mortality conferences, institutional root cause analyses, and an abdominal pain trigger tool were the most frequent domains for detecting diagnostic errors. Appendicitis, fractures, and nonaccidental trauma were the 3 most common diagnoses that were missed or had delayed identification.

CONCLUSIONS

A QI initiative successfully created a pragmatic approach to identify and measure diagnostic errors by utilizing a DEI. The DEI established a framework to help guide future initiatives to reduce diagnostic errors.

Pediatric Clinician Comfort Discussing Diagnostic Errors for Improving Patient Safety: A Survey

INTRODUCTION

Meaningful conversations about diagnostic errors require safety cultures where clinicians are comfortable discussing errors openly. However, clinician comfort discussing diagnostic errors publicly and barriers to these discussions remain unexplored. We compared clinicians' comfort discussing diagnostic errors to other medical errors and identified barriers to open discussion.

METHODS

Pediatric clinicians at 4 hospitals were surveyed between May and June 2018. The survey assessed respondents' comfort discussing medical errors (with varying degrees of system versus individual clinician responsibility) during morbidity and mortality conferences and privately with peers. Respondents reported the most significant barriers to discussing diagnostic errors publicly. Poststratification weighting accounted for nonresponse bias; the Benjamini-Hochberg adjustment was applied to control for false discovery (significance set at P < 0.018).

RESULTS

Clinicians (n = 838; response rate 22.6%) were significantly less comfortable discussing all error types during morbidity and mortality conferences than privately (P < 0.004) and significantly less comfortable discussing diagnostic errors compared with other medical errors (P < 0.018). Comfort did not differ by clinician type or years in practice; clinicians at one institution were significantly less comfortable discussing diagnostic errors compared with peers at other institutions. The most frequently cited barriers to discussing diagnostic errors publicly included feeling like a bad clinician, loss of reputation, and peer judgment of knowledge base and decision-making.

CONCLUSIONS

Clinicians are more uncomfortable discussing diagnostic errors than other types of medical errors. The most frequent barriers involve the public perception of clinical performance. Addressing this aspect of safety culture may improve clinician participation in efforts to reduce harm from diagnostic errors.

Can a Woman of Color Trust Medical Education?

In this Invited Commentary, the author-a second-generation immigrant, a first-generation college graduate, and a woman of color-reflects on the experiences during medical school that shaped her trust in the medical education system. She describes her reasons for entering medicine-to become the kind of doctor she wished she had had growing up. Then she considers how the words physicians use with patients and to talk about patients, which can reinforce problematic narratives and indicate complicity with structural injustices, negatively affect the care they provide. Trainees learn what is acceptable behavior from this hidden curriculum, perpetuating these harmful practices. The author challenges readers to consider how leaders in medical education can work to change this culture to create an education system that trains a physician workforce that keeps patients' voices and experiences at the center of their care and serves the needs of all patients, regardless of their identities.

Quality improvement in pediatric intensive care: A systematic review of the literature

IMPORTANCE

Measuring and improving performance is an essential component of any high-risk industry, including intensive care medicine. We undertook this systematic review to describe the current state of quality improvement efforts in pediatric intensive care medicine.

OBJECTIVE

To evaluate the quality and rigor of all published literature on quality improvement efforts in the pediatric intensive care unit in the current era.

METHODS

We conducted a literature search on MEDLINE, Embase, and Cochrane for studies that met two broad inclusion criteria: 1) the terms "pediatric critical care" and "quality improvement" and 2) they were completed in the past ten years. In the initial search, we also included academic and professional societies or organizations devoted to providing resources on quality improvement in intensive care medicine. We excluded studies that examined quality improvement processes exclusively for neonatal or adult patients receiving intensive care.

RESULTS

Forty-nine of 332 identified articles were selected for final review by two reviewers who independently rated the quality of the methodology and rigor of the evidence reported for each study. Of these, 23 studies targeted structural issues, 14 studies targeted process issues, and 12 targeted an outcome as the focus of the intensive care quality improvement effort.

INTERPRETATION

Our review of the published literature on quality improvement efforts in the pediatric intensive care unit in the current era found that 85% of studies were limited in methodology or analysis. Fifteen high-quality studies are reported here and serve as helpful examples of rigorous research methodology in this domain going forward.