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Lahnaoui O, Houmada A, Benkabbou A, Ghannam A, Al Ahmadi B, Belkhadir Z, Mohsine R, Souadka A, Majbar MA. Enhancing patient safety: a system-based analysis of morbidity and mortality conferences in managing postoperative bleeding following gastric and pancreatic cancer surgery. BMJ Open Qual 2024; 13:e002657. [PMID: 38485113 PMCID: PMC10941144 DOI: 10.1136/bmjoq-2023-002657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
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%.
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Affiliation(s)
- Oumayma Lahnaoui
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amina Houmada
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amine Benkabbou
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Abdelillah Ghannam
- National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Brahim Al Ahmadi
- National Institute of Oncology - Intensive Care Department, Mohammed V Souissi University, Rabat, Morocco
| | - Zakaria Belkhadir
- National Institute of Oncology - Intensive Care Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Raouf Mohsine
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Amine Souadka
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
| | - Mohammed Anass Majbar
- National Institute of Oncology - Surgical Oncology Department, Mohammed V University in Rabat, Rabat, Morocco
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Jeffs EL, Delany C, Newall F, Kinney S. Goals of the Morbidity and Mortality meeting in acute care: A scoping review. Aust Crit Care 2024; 37:185-192. [PMID: 38016842 DOI: 10.1016/j.aucc.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 11/30/2023] Open
Abstract
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.
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Affiliation(s)
- Emma Louise Jeffs
- The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3010, Australia; The University of Melbourne, Parkville, Victoria, 3010, Australia.
| | - Clare Delany
- The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3010, Australia; The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Fiona Newall
- The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3010, Australia; The University of Melbourne, Parkville, Victoria, 3010, Australia
| | - Sharon Kinney
- The Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria, 3010, Australia; The University of Melbourne, Parkville, Victoria, 3010, Australia
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Adhikari B, Mishra SR, Schwarz R. Transforming Nepal's primary health care delivery system in global health era: addressing historical and current implementation challenges. Global Health 2022; 18:8. [PMID: 35101073 PMCID: PMC8802254 DOI: 10.1186/s12992-022-00798-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/08/2022] [Indexed: 02/07/2023] Open
Abstract
Nepal’s Primary Health Care (PHC) is aligned vertically with disease control programs at the core and a vast network of community health workers at the periphery. Aligning with the globalization of health and the factors affecting global burden of diseases, Nepal echoes the progressive increase in life expectancy, changes in diseases patterns, including the current impact of COVID-19. Nepal’s health system is also accommodating recent federalization, and thus it is critical to explore how the primary health care system is grappling the challenges amidst these changes. In this review, we conducted a narrative synthesis of literature to explore the challenges related to transformation of Nepal’s primary health care delivery system to meet the demands incurred by impact of globalization and recent federalization, covering following database: PubMED, Embase and Google Scholar. Of the 49 articles abstracted for full text review, 37 were included in the analyses. Existing theories were used for constructing the conceptual framework to explain the study findings. The results are divided into four themes. Additional searches were conducted to further support the narrative synthesis: a total of 46 articles were further included in the articulation of main findings. Transforming Nepal’s primary health care system requires a clear focus on following priority areas that include i) Revised efforts towards strengthening of community based primary health care units; ii) Adapting vertical programs to federal governance; iii) Reinforcing the health insurance scheme; and iv) Strengthening an existing network of community health workers and health human resources. This review discusses how these broad goals bear challenges and opportunities.
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Affiliation(s)
- Bipin Adhikari
- Nepal Community Health and Development Centre, Kathmandu, Nepal. .,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Ryan Schwarz
- Possible, New York, NY, USA.,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA
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Lazzara EH, Salisbury M, Hughes AM, Rogers JE, King HB, Salas E. The Morbidity and Mortality Conference: Opportunities for Enhancing Patient Safety. J Patient Saf 2022; 18:e275-e281. [PMID: 34951610 DOI: 10.1097/pts.0000000000000765] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Elizabeth H Lazzara
- From the Department of Human Factors and Behavioral Neurobiology, Embry Riddle Aeronautical University, Daytona Beach, Florida
| | | | - Ashley M Hughes
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL
| | - Jordan E Rogers
- From the Department of Human Factors and Behavioral Neurobiology, Embry Riddle Aeronautical University, Daytona Beach, Florida
| | - Heidi B King
- U.S. Department of Defense Patient Safety Program, Defense Health Agency, Falls Church, Virginia
| | - Eduardo Salas
- Department of Psychology, Rice University, Houston, Texas
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Shrestha R, Shrestha AP, Sonnenberg T, Mistry J, Shrestha R, MacKinney T. Needs Assessment and Identification of the Multifaceted COPD Care Bundle in the Emergency Department of a Tertiary Hospital in Nepal. Int J Chron Obstruct Pulmon Dis 2021; 16:125-136. [PMID: 33519197 PMCID: PMC7837591 DOI: 10.2147/copd.s285744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/30/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Acute care of patients with exacerbation of chronic obstructive pulmonary disease (AECOPD) in the emergency department (ED) is crucial, however not studied extensively in Nepal. The purpose of this study is to identify the opportunities for succinct measures to optimize the AECOPD care in ED with a multifaceted bundle care approach in a resource-limited setting. Methods We conducted a prospective cross-sectional observational study as an initial baseline stage of the quality improvement project. Demographic data, clinical characteristics, the current diagnosis and treatment performances of AECOPD were recorded. The primary outcome measures were 30-day ED revisit and near-fatal events which were compared with other variables and performances with binary and logistic regression. The multidisciplinary team performed the root cause and Pareto analysis to identify the potential gaps in the AECOPD care. Results The AECOPD performance measures were suboptimal. Written AECOPD emergency management clinical guidelines and advice regarding pulmonary rehabilitation were absent. Among the 249 AECOPD encounters, bilevel positive-airway pressure ventilation was started in 6.4%. At discharge, 11.8% and 39.7% were given oral steroids and antibiotics respectively; 2.2% were advised vaccination. Near-fatal events and 30-day revisit occurred in 19% and 38.2% of the encounters respectively. Those who required domiciliary oxygen had significantly higher 30-day revisits (OR=2.5; 95% CI=1.43-4.4; P value =0.001) as did those who were previously admitted (OR=1.98; 95% CI 1.11-3.59; P value =0.022). Those who had a 30-day revisit had increased near-fatal events (OR=2.86; 95% CI=1.362-6.18; P value =0.006). The opportunities for improving the ED care were identified and feasible interventions and their indicators are summarized for future implementation. Conclusion The current COPD performance measures were suboptimal with high 30-day revisit and near-fatal outcomes. We suggest the urgent implementation of the enlisted feasible bundles-care involving multifaceted team and protocol-based management plans for AECOPD in a busy resource-limited ED.
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Affiliation(s)
- Roshana Shrestha
- Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
| | - Anmol Purna Shrestha
- Department of General Practice and Emergency Medicine, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal
| | - Taylor Sonnenberg
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Janki Mistry
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Rajeev Shrestha
- Department of Pharmacology, Kathmandu University School of Medical Sciences, Dhulikhel, Kavrepalanchok, Nepal.,Nepal Pharmacovigilance Unit/Research & Development Division, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Kavrepalanchok, Nepal
| | - Theodore MacKinney
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Bruny J, Inge T, Rannie M, Acker S, Levitt G, Cumbler E, Brumbaugh D. Transforming surgical morbidity and mortality into a systematic case review. J Pediatr Surg 2021; 56:80-84. [PMID: 33139023 DOI: 10.1016/j.jpedsurg.2020.09.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE The surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement. METHODS An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019. RESULTS For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content. CONCLUSION Creation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review. TYPE OF STUDY Retrospective Historical control; Quality improvement. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jennifer Bruny
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO.
| | - Thomas Inge
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | - Shannon Acker
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
| | | | | | - David Brumbaugh
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Aurora, CO
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Schwarz D, Dhungana S, Kumar A, Acharya B, Agrawal P, Aryal A, Baum A, Choudhury N, Citrin D, Dangal B, Dhimal M, Gauchan B, Gupta T, Halliday S, Karmacharya B, Kishore S, Koirala B, Kshatriya U, Levine E, Maru S, Rimal P, Sapkota S, Schwarz R, Shrestha A, Thapa A, Maru D. An integrated intervention for chronic care management in rural Nepal: protocol of a type 2 hybrid effectiveness-implementation study. Trials 2020; 21:119. [PMID: 31996250 PMCID: PMC6990567 DOI: 10.1186/s13063-020-4063-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 01/09/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND In Nepal, the burden of noncommunicable, chronic diseases is rapidly rising, and disproportionately affecting low and middle-income countries. Integrated interventions are essential in strengthening primary care systems and addressing the burden of multiple comorbidities. A growing body of literature supports the involvement of frontline providers, namely mid-level practitioners and community health workers, in chronic care management. Important operational questions remain, however, around the digital, training, and supervisory structures to support the implementation of effective, affordable, and equitable chronic care management programs. METHODS A 12-month, population-level, type 2 hybrid effectiveness-implementation study will be conducted in rural Nepal to evaluate an integrated noncommunicable disease care management intervention within Nepal's new municipal governance structure. The intervention will leverage the government's planned roll-out of the World Health Organization's Package of Essential Noncommunicable Disease Interventions (WHO-PEN) program in four municipalities in Nepal, with a study population of 80,000. The intervention will leverage both the WHO-PEN and its cardiovascular disease-specific technical guidelines (HEARTS), and will include three evidence-based components: noncommunicable disease care provision using mid-level practitioners and community health workers; digital clinical decision support tools to ensure delivery of evidence-based care; and training and digitally supported supervision of mid-level practitioners to provide motivational interviewing for modifiable risk factor optimization, with a focus on medication adherence, and tobacco and alcohol use. The study will evaluate effectiveness using a pre-post design with stepped implementation. The primary outcomes will be disease-specific, "at-goal" metrics of chronic care management; secondary outcomes will include alcohol and tobacco consumption levels. DISCUSSION This is the first population-level, hybrid effectiveness-implementation study of an integrated chronic care management intervention in Nepal. As low and middle-income countries plan for the Sustainable Development Goals and universal health coverage, the results of this pragmatic study will offer insights into policy and programmatic design for noncommunicable disease care management in the future. TRIAL REGISTRATION ClinicalTrials.gov, NCT04087369. Registered on 12 September 2019.
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Affiliation(s)
- Dan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
- Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women’s Hospital, Boston, MA USA
| | - Santosh Dhungana
- Department of Internal Medicine, Hurley Medical Center, Flint, MI USA
| | - Anirudh Kumar
- Department of Medicine, NYU Langone Health, New York, NY USA
| | - Bibhav Acharya
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, University of California San Francisco, San Francisco, CA USA
| | | | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
| | - Aaron Baum
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Nandini Choudhury
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - David Citrin
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Anthropology, University of Washington, Seattle, WA USA
- Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | | | - Meghnath Dhimal
- Nepal Health Research Council, Ministry of Health and Population, Kathmandu, Nepal
| | | | - Tula Gupta
- Nyaya Health Nepal, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Scott Halliday
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Biraj Karmacharya
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
- Nepal Technology Innovation Center, Kathmandu University, Dhulikhel, Nepal
- Sun Yat-sen Global Health Institute, Sun Yat-sen University, Guangzhou, China
| | - Sandeep Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Young Professionals Chronic Disease Network, New York, NY USA
| | - Bhagawan Koirala
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Erica Levine
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Sheela Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | | | - Sabitri Sapkota
- Nyaya Health Nepal, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Ryan Schwarz
- Nyaya Health Nepal, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Archana Shrestha
- School of Medical Sciences, Kathmandu University, Dhulikhel, Nepal
- Yale School of Public Health, Center for Methods in Implementation and Prevention Science, New Haven, CT USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT USA
| | | | - Duncan Maru
- Nyaya Health Nepal, Kathmandu, Nepal
- Department of Psychiatry, University of California San Francisco, San Francisco, CA USA
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
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Joseph CW, Garrubba ML, Melder AM. Informing best practice for conducting morbidity and mortality reviews: a literature review. AUST HEALTH REV 2019; 42:248-257. [PMID: 30021683 DOI: 10.1071/ah16193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022]
Abstract
Objective Preventable hospital mortality is a critical public health issue, particularly when mortalities are associated with events that are preventable. Mortality and morbidity reviews (MMRs) provide a rigorous, systematic, open, collaborative and transparent review process for clinicians to examine areas of improvement. The aim of the present review was to explore the evidence for best practice when conducting MMRs. Methods Searches of published and grey literature from 2009 to February 2016 were conducted. This period was selected to update a previous review. Inclusion and exclusion criteria was established a priori and based on the Population-Intervention-Comparison-Outcome (PICO) framework. Specific search terms were generated and used to identify relevant articles, with reference lists and citing articles also screened for inclusions. Titles and abstracts were screened and duplicates removed. Study details regarding setting, study design, reported outcomes, tool type, clinicians present and the timing of MMRs were extracted and summarised. Results After screening, 31 documents were included in the present review: 20 peer-reviewed articles and 11 items from the grey literature. Specific outcomes reported included mortality rates, satisfaction, education, cost and quality of care. The most common features of MMRs included timing, leadership, attendees, case presentation format, terms of reference, agenda and governance. Conclusions MMRs decrease gross mortality rates and are effective in identifying and engaging clinicians in system improvements. MMRs should not focus on the actions of individuals, rather on education and/or quality improvement. MMRs should consist of a multidisciplinary team following a structured presentation format with an analysis of error process including actions to be followed-up. Further, it is possible for a single standardised MMR to be implemented hospital wide. What is known about the topic? MMRs are conducted in a variety of clinical settings to educate clinicians and improve patient care. What does this paper add? This review updates a previous review published in 2009 and summarises current evidence around morbidity and mortality reviews. This review also provides a framework for a standardised MMR to be implemented hospital wide. What are the implications for practitioners? This summary of the evidence can be used to guide the development, formation or conduct of MMRs in any healthcare setting.
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Affiliation(s)
- Corey W Joseph
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
| | - Marie L Garrubba
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
| | - Angela M Melder
- Centre for Clinical Effectiveness, Monash Health, 246 Clayton Road, Clayton, Vic. 3168, Australia.
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Mehanni S, Wong L, Acharya B, Agrawal P, Aryal A, Basnet M, Citrin D, Dangal B, Deukmedjian G, Dhungana SK, Gauchan B, Gupta TK, Halliday S, Kalaunee SP, Kshatriya U, Kumar A, Maru D, Maru S, Nguyen V, Paudel JS, Rimal P, Saleh M, Schwarz R, Swar SB, Thapa A, Tiwari A, White R, Wu WJ, Schwarz D. Transition to active learning in rural Nepal: an adaptable and scalable curriculum development model. BMC MEDICAL EDUCATION 2019; 19:61. [PMID: 30786884 PMCID: PMC6383231 DOI: 10.1186/s12909-019-1492-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 02/12/2019] [Indexed: 05/24/2023]
Abstract
BACKGROUND Traditional medical education in much of the world has historically relied on passive learning. Although active learning has been in the medical education literature for decades, its incorporation into practice has been inconsistent. We describe and analyze the implementation of a multidisciplinary continuing medical education curriculum in a rural Nepali district hospital, for which a core objective was an organizational shift towards active learning. METHODS The intervention occurred in a district hospital in remote Nepal, staffed primarily by mid-level providers. Before the intervention, education sessions included traditional didactics. We conducted a mixed-methods needs assessment to determine the content and educational strategies for a revised curriculum. Our goal was to develop an effective, relevant, and acceptable curriculum, which could facilitate active learning. As part of the intervention, physicians acted as both learners and teachers by creating and delivering lectures. Presenters used lecture templates to prioritize clarity, relevance, and audience engagement, including discussion questions and clinical cases. Two 6-month curricular cycles were completed during the study period. Daily lecture evaluations assessed ease of understanding, relevance, clinical practice change, and participation. Periodic lecture audits recorded learner talk-time, the proportion of lecture time during which learners were talking, as a surrogate for active learning. Feedback from evaluation and audit results was provided to presenters, and pre- and post-curriculum knowledge assessment exams were conducted. RESULTS Lecture audits showed a significant increase in learner talk-time, from 14% at baseline to 30% between months 3-6, maintained at 31% through months 6-12. Lecture evaluations demonstrated satisfaction with the curriculum. Pre- and post-curriculum knowledge assessment scores improved from 50 to 64% (difference 13.3% ± 4.5%, p = 0.006). As an outcome for the measure of organizational change, the curriculum was replicated at an additional clinical site. CONCLUSION We demonstrate that active learning can be facilitated by implementing a new educational strategy. Lecture audits proved useful for internal program improvement. The components of the intervention which are transferable to other rural settings include the use of learners as teachers, lecture templates, and provision of immediate feedback. This curricular model could be adapted to similar settings in Nepal, and globally.
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Affiliation(s)
- Stephen Mehanni
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
- Gallup Indian Medical Center, Gallup, NM USA
| | - Lena Wong
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
- Tuba City Regional Health Care, Tuba City, AZ USA
| | - Bibhav Acharya
- Possible, Kathmandu, Nepal
- Department of Psychiatry, University of California San Francisco, San Francisco, CA USA
| | | | | | - Madhur Basnet
- Possible, Kathmandu, Nepal
- Department of Psychiatry, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - David Citrin
- Possible, Kathmandu, Nepal
- Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
- Department of Global Health, University of Washington, Seattle, WA USA
- Department of Anthropology, University of Washington, Seattle, WA USA
| | | | - Grace Deukmedjian
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
- Department of Pediatrics, Natividad Medical Center, Salinas, CA USA
| | | | - Bikash Gauchan
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | | | - Scott Halliday
- Possible, Kathmandu, Nepal
- Henry M. Jackson School of International Studies, University of Washington, Seattle, WA USA
| | - S. P. Kalaunee
- Possible, Kathmandu, Nepal
- College of Business and Leadership, Eastern University, St. Davids, PA USA
| | | | - Anirudh Kumar
- Possible, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Duncan Maru
- Possible, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Sheela Maru
- Possible, Kathmandu, Nepal
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, NY USA
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Viet Nguyen
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Jhalak Sharma Paudel
- National Health Training Center, Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal
| | - Pragya Rimal
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Marwa Saleh
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Ryan Schwarz
- Possible, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA USA
| | - Sikhar Bahadur Swar
- Possible, Kathmandu, Nepal
- Department of Psychiatry, Kathmandu Medical College, Kathmandu, Nepal
| | | | | | - Rebecca White
- Possible, Kathmandu, Nepal
- Health Equity Action Leadership Initiative, University of California, San Francisco, San Francisco, CA USA
| | - Wan-Ju Wu
- Possible, Kathmandu, Nepal
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA USA
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Dan Schwarz
- Possible, Kathmandu, Nepal
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Department of Medicine, Harvard Medical School, Boston, MA USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
- Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, MA USA
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10
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Radhakrishnan NS, Lo MC, Bishnoi R, Samal S, Leverence R, Rosenberg E, Zaidi Z. A resident-driven mortality case review innovation to teach and drive system-based practice improvements in the United States. JOURNAL OF EDUCATIONAL EVALUATION FOR HEALTH PROFESSIONS 2018; 15:31. [PMID: 30586955 PMCID: PMC6451922 DOI: 10.3352/jeehp.2018.15.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/26/2000] [Indexed: 06/09/2023]
Abstract
PURPOSE Traditionally, Morbidity and Mortality Conference (M&MC) are forums where medical errors are discussed. Though M&MC can lead to identification of opportunities for system wide improvements, there is little in the literature to describe the use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches systems-based practice and can engage residents in improving systems of care. METHODS Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2104 to September 2017. Residents used case review worksheets to categorize and track causes of mortality. The residents then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. RESULTS The residents identified a diagnosis mismatch from admission to death in 54.5 % (n=189) of cases and possible need for improvement in management in 48.0% cases. Three 'management failure' themes were identified including failures to plan, failure to communicate and failure to rescue, consisting of 21.9%, 10.7 %, and 10.1% of cases respectively. Following the reviews, quality improvement initiatives proposed by residents lead to system-based changes. CONCLUSION A resident-driven mortality review curriculum can lead to improvement in systems of care. This type of novel curriculum can teach systems-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.
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Affiliation(s)
- Nila S. Radhakrishnan
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Margaret C. Lo
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rohit Bishnoi
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Subhankar Samal
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Robert Leverence
- Department of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Eric Rosenberg
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Zareen Zaidi
- Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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11
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Anderson E, Sandars J, Kinnair D. The nature and benefits of team-based reflection on a patient death by healthcare professionals: a scoping review. J Interprof Care 2018; 33:15-25. [DOI: 10.1080/13561820.2018.1513462] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Elizabeth Anderson
- College of Medicine, Biological Sciences and Psychology,Centre for Medicine, University of Leicester, University Road, Leicester, UK
| | - John Sandars
- Postgraduate Medical Institute, Edge Hill University Medical School, UK
| | - Daniel Kinnair
- Consultant General Adult Psychiatrist, and Honorary Associate Professor at Leicester Medical School, UK
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12
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Gauchan B, Mehanni S, Agrawal P, Pathak M, Dhungana S. Role of the general practitioner in improving rural healthcare access: a case from Nepal. HUMAN RESOURCES FOR HEALTH 2018; 16:23. [PMID: 29747669 PMCID: PMC5946403 DOI: 10.1186/s12960-018-0287-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 04/20/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND There is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital. CASE PRESENTATION We perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital's catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives. CONCLUSIONS GPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal's maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal's public sector.
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Affiliation(s)
- Bikash Gauchan
- Possible, 700 Bluebird Complex, Floor 7, Tripureshwor, Kathmandu Nepal
| | - Stephen Mehanni
- Possible, 700 Bluebird Complex, Floor 7, Tripureshwor, Kathmandu Nepal
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA United States of America
| | - Pawan Agrawal
- Possible, 700 Bluebird Complex, Floor 7, Tripureshwor, Kathmandu Nepal
| | - Mandeep Pathak
- Possible, 700 Bluebird Complex, Floor 7, Tripureshwor, Kathmandu Nepal
| | - Santosh Dhungana
- Possible, 700 Bluebird Complex, Floor 7, Tripureshwor, Kathmandu Nepal
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13
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Maru S, Nirola I, Thapa A, Thapa P, Kunwar L, Wu WJ, Halliday S, Citrin D, Schwarz R, Basnett I, Kc N, Karki K, Chaudhari P, Maru D. An integrated community health worker intervention in rural Nepal: a type 2 hybrid effectiveness-implementation study protocol. Implement Sci 2018; 13:53. [PMID: 29598824 PMCID: PMC5875011 DOI: 10.1186/s13012-018-0741-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/13/2018] [Indexed: 11/13/2022] Open
Abstract
Background Evidence-based medicines, technologies, and protocols exist to prevent many of the annual 300,000 maternal, 2.7 million neonatal, and 9 million child deaths, but they are not being effectively implemented and utilized in rural areas. Nepal, one of South Asia’s poorest countries with over 80% of its population living in rural areas, exemplifies this challenge. Community health workers are an important cadre in low-income countries where human resources for health and health care infrastructure are limited. As local women, they are uniquely positioned to understand and successfully navigate barriers to health care access. Recent case studies of large community health worker programs have highlighted the importance of training, both initial and ongoing, and accountability through structured management, salaries, and ongoing monitoring and evaluation. A gap in the evidence regarding whether such community health worker systems can change health outcomes, as well as be sustainably adopted at scale, remains. In this study, we plan to evaluate a community health worker system delivering an evidence-based integrated reproductive, maternal, newborn, and child health intervention as it is scaled up in rural Nepal. Methods We will conduct a type 2 hybrid effectiveness-implementation study to test both the effect of an integrated reproductive, maternal, newborn, and child health intervention and the implementation process via a professional community health worker system. The intervention integrates five evidence-based approaches: (1) home-based antenatal care and post-natal care counseling and care coordination; (2) continuous surveillance of all reproductive age women, pregnancies, and children under age 2 years via a mobile application; (3) Community-Based Integrated Management of Newborn and Childhood Illness; (4) group antenatal and postnatal care; and 5) the Balanced Counseling Strategy to post-partum contraception. We will evaluate effectiveness using a pre-post quasi-experimental design with stepped implementation and implementation using the RE-AIM framework. Discussion This is the first hybrid effectiveness-implementation study of an integrated reproductive, maternal, newborn, and child health intervention in rural Nepal that we are aware of. As Nepal takes steps towards achieving the Sustainable Development Goals, the data from this three-year study will be useful in the detailed planning of a professionalized community health worker cadre delivering evidence-based reproductive, maternal, newborn, and child health interventions to the country’s rural population. Trial registration ClinicalTrials.gov Identifier: NCT03371186, registered 04 December 2017, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13012-018-0741-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sheela Maru
- Possible, Kathmandu, Nepal.,Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA.,Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, USA
| | - Isha Nirola
- Possible, Kathmandu, Nepal.,Department Medicine, Division of Women's Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Wan-Ju Wu
- Possible, Kathmandu, Nepal.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Scott Halliday
- Possible, Kathmandu, Nepal.,Henry M. Jackson School of International Studies, University of Washington, Seattle, WA, USA
| | - David Citrin
- Possible, Kathmandu, Nepal.,Henry M. Jackson School of International Studies, University of Washington, Seattle, WA, USA.,Department of Anthropology, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Ryan Schwarz
- Possible, Kathmandu, Nepal.,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Department of Medicine, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Indira Basnett
- Department of Health Services, Nepal Health Sector Programme, Ministry of Health, Kathmandu, Nepal
| | - Naresh Kc
- Department of Health Services, Family Health Division, Ministry of Health, Kathmandu, Nepal
| | - Khem Karki
- Department of Community Medicine, Tribhuvan University, Institute of Medicine, Kathmandu, Nepal
| | - Pushpa Chaudhari
- Department of Health Services, Ministry of Health, Kathmandu, Nepal
| | - Duncan Maru
- Possible, Kathmandu, Nepal. .,Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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14
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Pang DSJ, Rousseau-Blass F, Pang JM. Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine. Front Vet Sci 2018; 5:43. [PMID: 29560359 PMCID: PMC5845710 DOI: 10.3389/fvets.2018.00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/21/2018] [Indexed: 11/30/2022] Open
Abstract
This mini review presents current knowledge on the role of morbidity and mortality conferences (M&MCs) as a powerful educational tool and driver to improve patient care. Although M&MCs have existed since the early twentieth century, formal evaluation of their impact on education and patient care is relatively recent. Over time, M&MCs have evolved from single discipline discussions with a tendency to focus on individual errors and assign blame, to multidisciplinary, standardized presentations incorporating error analysis techniques, and educational theory. Current evidence shows that M&MCs can provide a valuable educational experience and have the potential to generate measurable improvements in patient care.
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Affiliation(s)
- Daniel S J Pang
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Frédérik Rousseau-Blass
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Jessica M Pang
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
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15
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Wang S, Vogt A. Mortality review as a teaching tool in the tropics. CLINICAL TEACHER 2018; 15:78-80. [DOI: 10.1111/tct.12675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Rouch JD, Dawes AJ, Garber K, Sukhudyan B, Shekherdimian S. Attitudes Toward Morbidity and Mortality Conferences Among Medical and Surgical Pediatric Specialists in Armenia. JAMA Surg 2017; 152:1178-1180. [PMID: 28854297 DOI: 10.1001/jamasurg.2017.2974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joshua D Rouch
- Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Aaron J Dawes
- Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kent Garber
- Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Biayna Sukhudyan
- Division of Pediatric Neurology, Arabkir Joint Medical Center, Yerevan, Armenia
| | - Shant Shekherdimian
- Division of Pediatric Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California
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17
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Benassi P, MacGillivray L, Silver I, Sockalingam S. The role of morbidity and mortality rounds in medical education: a scoping review. MEDICAL EDUCATION 2017; 51:469-479. [PMID: 28294382 DOI: 10.1111/medu.13234] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/21/2016] [Accepted: 10/11/2016] [Indexed: 06/06/2023]
Abstract
CONTEXT There is increasing focus on how health care professionals can be trained effectively in quality improvement and patient safety principles. The morbidity and mortality round (MMR) has often been used as a tool with which to examine and teach care quality, yet little is known of its implementation and educational outcomes. OBJECTIVES The objectives of this scoping review are to examine and summarise the literature on how the MMR is designed and delivered, and to identify how it is evaluated for effectiveness in addressing medical education outcomes. METHODS A literature search of the PubMed, MEDLINE, PsycInfo and Cochrane Library databases was conducted for articles published from 1980 to 1 June 2016. Publications in English describing the design, implementation and evaluation of MMRs were included. A total of 67 studies were identified, including eight survey-based studies, four literature reviews, one ethnographic study, three opinion papers, two qualitative observation studies and 49 case studies of education programmes with or without formal evaluation. Study outcomes were categorised using Donald Moore's framework for the evaluation of continuing medical education (CME). RESULTS There is much heterogeneity within the literature regarding the implementation, delivery and goals of the MMR. Common design components included explicit programme goals and objectives, the case selection process, case presentation models and some form of case analysis. Evaluation of CME outcomes for MMR were mainly limited to learner participation, satisfaction and self-assessed changes in knowledge. CONCLUSIONS The MMR is widely utilised as an educational tool to promote medical education, patient safety and quality improvement. Although evidence to guide the design and implementation of the MMR to achieve measurable CME outcomes remains limited, there are components associated with positive improvements to learning and performance outcomes.
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Affiliation(s)
- Paul Benassi
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lindsey MacGillivray
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ivan Silver
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Sanjeev Sockalingam
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
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18
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Bock A, Chintamaneni K, Rein L, Frazer T, Kayastha G, MacKinney T. Improving pneumococcal vaccination rates of medical inpatients in urban Nepal using quality improvement measures. BMJ QUALITY IMPROVEMENT REPORTS 2016; 5:bmjquality_uu212047.w4835. [PMID: 27933153 PMCID: PMC5128775 DOI: 10.1136/bmjquality.u212047.w4835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/03/2016] [Indexed: 12/03/2022]
Abstract
Streptococcus pneumoniae infection is associated with high morbidity and mortality in low income countries. In Nepal, there is a high lung disease burden and incidence of pneumonia due to multiple factors including indoor air pollution, dust exposure, recurrent infections, and cigarette smoking. Despite the ready availability of effective pneumococcal vaccines (PNV), vaccine coverage rates remain suboptimal globally. Quality Improvement (QI) principles could be applied to improve compliance, but it is a virtually new technology in Nepal. This QI study for Patan Hospital sought to introduce the concept of QI there, to measure the baseline pneumococcal vaccination rate of qualifying adult patients discharged from the medical wards and to assess reasons for non-vaccination. QI interventions were instituted to improve this rate, measuring the effectiveness of QI methods to produce the desired outcomes using the Model for Improvement, Plan-Do-Study-Change (PDSA) methodology. In the three week baseline assessment, 2 out of 81 (2%) eligible patients recalled ever receiving a prior pneumococcal vaccine; 68 (84%) unvaccinated patients responded that they were not asked or were unaware of the PNV. After the QI interventions, the pneumococcal vaccination rate significantly increased to 42% (23/56, p<0.001). Post-intervention, the leading reason for non-vaccination was cost (20%, 11/56). Only 5 (9%) unvaccinated patients were not asked or were unaware of the PNV, a significant change in that process outcome from baseline (p<0.001). Quality improvement measures were effective in increasing pneumococcal vaccination rates, despite the limited familiarity with QI methods at this major teaching hospital. QI techniques may be useful in this and other efforts to improve quality in resource-limited settings, without great cost.
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19
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Gregor A, Taylor D. Morbidity and Mortality Conference: Its Purpose Reclaimed and Grounded in Theory. TEACHING AND LEARNING IN MEDICINE 2016; 28:439-447. [PMID: 27285144 DOI: 10.1080/10401334.2016.1189335] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
ISSUE The morbidity and mortality conference (MMC) remains a central activity within the departments of our academic healthcare institutions. It is deeply rooted in the premise that we can learn from our mistakes, thereby improving the care we provide. Recent advances in our understanding of medical error and quality improvement have challenged the value of traditional models of MMC. As a result the purpose of MMC has become clouded and ill-defined: Is it an educational conference that promotes mastery of clinical acumen, or is it a venue to drive quality improvement by addressing systems-based issues in delivering care? Or can it serve both purposes? EVIDENCE Review of the history of MMC, the literature, and critical application of education theory demonstrates the source of the confusion and the challenges in viewing it through the exclusive lens of either education or quality improvement. Application of experiential learning theory helps resolve this discord showing how the conference facilitates the development of clinical mastery while informing quality improvement programs about important and relevant systems-based issues. IMPLICATION Building on this, we present a model for MMC involving five essential elements: case-based involving an adverse patient event, anonymity for participants, expert guided critical analysis, reframing understanding of the case presentation and related systems-based factors, and projection to practice change. This model builds on previously described models, is grounded in the literature, and helps clarify its role from both the educational and the quality improvement perspectives.
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Affiliation(s)
- Alexander Gregor
- a Department of Surgery , University of Toronto Faculty of Medicine , Toronto , Ontario , Canada
- b Queen's University School of Medicine , Kingston , Ontario , Canada
| | - David Taylor
- c Department of Internal Medicine , Queen's University , Kingston , Ontario , Canada
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20
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Kwok ESH, Calder LA, Barlow-Krelina E, Mackie C, Seely AJE, Cwinn AA, Worthington JR, Frank JR. Implementation of a structured hospital-wide morbidity and mortality rounds model. BMJ Qual Saf 2016; 26:439-448. [DOI: 10.1136/bmjqs-2016-005459] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/10/2016] [Accepted: 06/10/2016] [Indexed: 11/04/2022]
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21
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Lecoanet A, Vidal-Trecan G, Prate F, Quaranta JF, Sellier E, Guyomard A, Seigneurin A, François P. Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: a survey of participants' perceptions. BMC Health Serv Res 2016; 16:176. [PMID: 27169924 PMCID: PMC4865106 DOI: 10.1186/s12913-016-1431-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/05/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- André Lecoanet
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Gwenaëlle Vidal-Trecan
- Public health unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, Paris, F-75014, France.,Research Unit: METHODS team, INSERM U1153 (Centre de Recherche Epidémiologie Biostatistique, Sorbonne Paris Cité), Paris, F-75005, France.,Medical School, Paris Descartes University, Paris, F-75006, France
| | - Frédéric Prate
- Public Health Department, University Hospital, Nice, F-06003, France
| | | | - Elodie Sellier
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Alizé Guyomard
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Arnaud Seigneurin
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Patrice François
- Public Health Department, University Hospital, Grenoble, F-38043, France. .,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France.
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22
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François P, Prate F, Vidal-Trecan G, Quaranta JF, Labarere J, Sellier E. Characteristics of morbidity and mortality conferences associated with the implementation of patient safety improvement initiatives, an observational study. BMC Health Serv Res 2016; 16:35. [PMID: 26831501 PMCID: PMC4734851 DOI: 10.1186/s12913-016-1279-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 01/22/2016] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Patrice François
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France.
| | - Frédéric Prate
- Public Health Department, University Hospital, Nice, F-06003, France
| | - Gwenaëlle Vidal-Trecan
- Public Health Unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, and Research Unit, (INSERM U738), Paris Descartes University, Sorbonne Paris cite, Paris, F- 75014, France
| | | | - José Labarere
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France
| | - Elodie Sellier
- Quality of Care Unit, University Hospital, and Research Unit, TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38043, France
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Cromeens B, Brilli R, Kurtovic K, Kenney B, Nwomeh B, Besner GE. Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference. J Pediatr Surg 2016; 51:137-42. [PMID: 26581322 DOI: 10.1016/j.jpedsurg.2015.10.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND/PURPOSE The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care. METHODS A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items. RESULTS Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training. CONCLUSIONS Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
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Affiliation(s)
- Barrett Cromeens
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Richard Brilli
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kelli Kurtovic
- Department of Quality Improvement Services, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Gail E Besner
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
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Morbidity-mortality conference for adverse events associated with totally implanted venous access for cancer chemotherapy. Support Care Cancer 2015; 24:1857-63. [PMID: 26454864 DOI: 10.1007/s00520-015-2969-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Although considered safer than central venous catheters for administration of cancer chemotherapy, totally implanted venous access (TIVA) is associated with adverse events that may impair prognosis and quality of life of patients receiving chemotherapy. Our aim was to assess the feasibility and interest of surveillance of cancer chemotherapy TIVA-adverse events (AE), associated with morbidity-mortality conferences (MMCs) on TIVA-AE. METHODS We performed a prospective interventional study in two hospitals (a university hospital and a comprehensive care center). For each cancer chemotherapy care pathway within each hospital, we set up surveillance of TIVA-AE and MMC on these events. Patients included in surveillance were those with a TIVA either placed or used for chemotherapy cycles in one of the participating wards. Feasibility of MMC was assessed by the number of MMC meetings that actually took place and the number of participants at each meeting. The interest of MMC was assessed by the number of TIVA-AE identified and analyzed, and the number and type of improvement actions selected and actually implemented. RESULTS We recorded 0.41 adverse events per 1000 TIVA-day. MMCs were implemented in all care pathways, with sustained pluriprofessional attendance throughout the survey; 39 improvement actions were identified during meetings, and 18 were actually implemented. CONCLUSIONS Surveillance of TIVA-AE associated with MMC is feasible and helps change practices. It could be useful for improving care of patients undergoing cancer chemotherapy.
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Cosimi LA, Dam HV, Nguyen TQ, Ho HT, Do PT, Duc DN, Nguyen HT, Gardner B, Libman H, Pollack T, Hirschhorn LR. Integrated clinical and quality improvement coaching in Son La Province, Vietnam: a model of building public sector capacity for sustainable HIV care delivery. BMC Health Serv Res 2015; 15:269. [PMID: 26184505 PMCID: PMC4504451 DOI: 10.1186/s12913-015-0935-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 06/29/2015] [Indexed: 11/30/2022] Open
Abstract
Background The global scale-up of antiretroviral therapy included extensive training and onsite support to build the capacity of HIV health care workers. However, traditional efforts aimed at strengthening knowledge and skills often are not successful at improving gaps in the key health systems required for sustaining high quality care. Methods We trained and mentored existing staff of the Son La provincial health department and provincial HIV clinic to work as a provincial coaching team (PCT) to provide integrated coaching in clinical HIV skills and quality improvement (QI) to the HIV clinics in the province. Nine core indicators were measured through chart extraction by clinic and provincial staff at baseline and at 6 month intervals thereafter. Coaching from the team to each of the clinics, in both QI and clinical skills, was guided by results of performance measurements, gap analyses, and resulting QI plans. Results After 18 months, the PCT had successfully spread QI activities, and was independently providing regular coaching to the provincial general hospital clinic and six of the eight district clinics in the province. The frequency and type of coaching was determined by performance measurement results. Clinics completed a mean of five QI projects. Quality of HIV care was improved throughout all clinics with significant increases in seven of the indicators. Overall both the PCT activities and clinic performance were sustained after integration of the model into the Vietnam National QI Program. Conclusions We successfully built capacity of a team of public sector health care workers to provide integrated coaching in both clinical skills and QI across a province. The PCT is a feasible and effective model to spread and sustain quality activities and improve HIV care services in a decentralized rural setting.
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Affiliation(s)
- Lisa A Cosimi
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA. .,The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA, USA.
| | - Huong V Dam
- Son La Department of Health, Son La Province, Vietnam.
| | - Thai Q Nguyen
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 57 Ly Nam De St, Hanoi, Vietnam.
| | - Huyen T Ho
- Son La Department of Health, Son La Province, Vietnam.
| | - Phuong T Do
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 57 Ly Nam De St, Hanoi, Vietnam.
| | - Duat N Duc
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 57 Ly Nam De St, Hanoi, Vietnam.
| | - Huong T Nguyen
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 57 Ly Nam De St, Hanoi, Vietnam.
| | - Bridget Gardner
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA, USA.
| | - Howard Libman
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA, USA.
| | - Todd Pollack
- The Partnership for Health Advancement in Vietnam, Beth Israel Deaconess Medical Center, 57 Ly Nam De St, Hanoi, Vietnam.
| | - Lisa R Hirschhorn
- Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA. .,Ariadne Labs, a joint Partnership with Brigham and Women's Hospital and Harvard School of Public Health, Landmark Center, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA.
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Gonzalo JD, Bump GM, Huang GC, Herzig SJ. Implementation and evaluation of a multidisciplinary systems-focused internal medicine morbidity and mortality conference. J Grad Med Educ 2014; 6:139-46. [PMID: 24701325 PMCID: PMC3963772 DOI: 10.4300/jgme-d-13-00162.1] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 09/17/2013] [Accepted: 10/02/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Morbidity and mortality (M&M) conferences provide a forum for discussing adverse events and systems-based practice (SBP) issues; however, few models for implementing multidisciplinary, systems-focused M&M conferences exist. OBJECTIVE To implement a new systems-focused M&M conference and evaluate success in focusing on adverse events and systems issues in a nonpunitive, multidisciplinary manner. METHODS We implemented a new M&M conference into our large university-based internal medicine residency program. Using content analysis, we qualitatively analyzed audio recordings of M&M conferences from the first year of implementation (2010-2011) to determine the frequency of adverse events (injury resulting from medical care), SBP discussion, and allocation of blame. Multidisciplinary attendance was evaluated by attendance logs. Surveys assessed change in interns' perceptions of M&M conferences before and after the conference series (measured by median Likert-scale response) and trainee/faculty attitudes regarding the goal of M&M conferences. RESULTS There were 226 attendees (66 faculty, 160 residents/fellows) at 9 M&M conferences. Average attendance per conference was 71, with representation from 16 disciplines. All M&M conferences (100%) included adverse events, SBP discussion, and lacked explicit individual blame. Interns' perceptions improved, including their belief that the M&M conference's purpose is systems improvement (4.35 versus 4.71, P = .02) and complications are discussed without blame (3.81 versus 4.34, P = .01). After experiencing M&M conferences, trainees/faculty reported favorable ratings, including beliefs that the M&M conference is important for education (97%) and the purpose is systems improvement (95%). CONCLUSIONS The implementation of a new systems-focused M&M conference resulted in a conference series focusing on adverse events and associated system issues in a nonpunitive, multidisciplinary context.
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Abstract
Diagnostic errors are a major patient safety concern. Although the majority of diagnostic errors are partially attributable to cognitive mistakes, the most effective means of improving clinician cognition in order to achieve gains in diagnostic reliability are unclear. We propose a tripartite educational agenda for improving diagnostic performance among students, residents and practising physicians. This agenda includes strengthening the metacognitive abilities of clinicians, fostering intuitive reasoning and increasing awareness of the role of systems in the diagnostic process. The evidence supporting initiatives in each of these realms is reviewed and a course of future implementation and study is proposed. The barriers to designing and implementing this agenda are substantial and include limited evidence supporting these initiatives and the challenges of changing the practice patterns of practising physicians. Implementation will need to be accompanied by rigorous evaluation.
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Deshpande JK, Throop PG, Slayton JM. Standardization of case reviews (morbidity and mortality rounds) promotes patient safety. Pediatr Clin North Am 2012; 59:1307-15. [PMID: 23116527 DOI: 10.1016/j.pcl.2012.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The morbidity and mortality conference (M&M) is a long-standing practice in medicine. Originally created to identify errors and improve care, the primary focus of M&M has moved toward an emphasis on education of trainees. A structured format for the M&M conference can help the interdisciplinary team address causes of adverse patient outcomes and identify opportunities for systems improvement.
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Affiliation(s)
- Jayant K Deshpande
- Departments of Pediatrics and Anesthesiology, Arkansas Children's Hospital and The University of Arkansas for Medical Sciences, Little Rock, AR 72202-3591, USA.
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Higginson J, Walters R, Fulop N. Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? BMJ Qual Saf 2012; 21:576-85. [PMID: 22556308 PMCID: PMC3382446 DOI: 10.1136/bmjqs-2011-000603] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction National Health Service hospitals and government agencies are increasingly using mortality rates to monitor the quality of inpatient care. Mortality and Morbidity (M&M) meetings, established to review deaths as part of professional learning, have the potential to provide hospital boards with the assurance that patients are not dying as a consequence of unsafe clinical practices. This paper examines whether and how these meetings can contribute to the governance of patient safety. Methods To understand the arrangement and role of M&M meetings in an English hospital, non-participant observations of meetings (n=9) and semistructured interviews with meeting chairs (n=19) were carried out. Following this, a structured mortality review process was codesigned and introduced into three clinical specialties over 12 months. A qualitative approach of observations (n=30) and interviews (n=40) was used to examine the impact on meetings and on frontline clinicians, managers and board members. Findings The initial study of M&M meetings showed a considerable variation in the way deaths were reviewed and a lack of integration of these meetings into the hospital's governance framework. The introduction of the standardised mortality review process strengthened these processes. Clinicians supported its inclusion into M&M meetings and managers and board members saw that a standardised trust-wide process offered greater levels of assurance. Conclusion M&M meetings already exist in many healthcare organisations and provide a governance resource that is underutilised. They can improve accountability of mortality data and support quality improvement without compromising professional learning, especially when facilitated by a standardised mortality review process.
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Affiliation(s)
- Juliet Higginson
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
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Maru DSR, Schwarz R, Schwarz D, Andrews J, Panizales MT, Karelas G, Brady JS, Rogers S. Implementing surgical services in a rural, resource-limited setting: a study protocol. BMJ Open 2011; 1:e000166. [PMID: 22021781 PMCID: PMC3191574 DOI: 10.1136/bmjopen-2011-000166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 07/05/2011] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION There are well-established protocols and procedures for the majority of common surgical diseases, yet surgical services remain largely inaccessible for much of the world's rural poor. Data on the process and outcome of surgical care expansion, however, are very limited, and the roll-out process of rural surgical implementation in particular has never been studied. Here, we propose the first implementation research study to assess the surgical scale-up process in the rural district of Achham, Nepal. METHODS AND ANALYSIS Based primarily on the protocols of the WHO's Integrated Management for Emergency and Essential Surgical Care (IMEESC), this study's threefold implementation strategy will include: (1) the core IMEESC surgical care program, (2) community-based follow-up via health workers, and (3) hospital-based quality improvement programs. The implementation program will employ additional emergency and surgical care protocols developed collaboratively by physicians, nurses and the authors. This strategy will be referred to as IMEESC-Plus. This study will employ both qualitative and quantitative research methodologies to collect clinical data and information on the reception and utilisation of services. The first 18 months of the implementation process will be studied and divided into an initial phase (first 6 months) and a consolidation phase (subsequent 12 months). DISCUSSION This study aims to describe the logistics of the implementation process of IMEESC-Plus, and assess the quality of the resulting IMEESC-Plus services during the course of the implementation process. Using data generated from this study, larger, multi-site implementation studies can be planned that assess the scale-up of surgical services worldwide in resource-limited areas.
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Affiliation(s)
- Duncan Smith-Rohrberg Maru
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ryan Schwarz
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Dan Schwarz
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
- School of Medicine, Brown University, Providence, Rhode Island, USA
| | - Jason Andrews
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Maria Theresa Panizales
- Department of Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gregory Karelas
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
| | - Jesse Stark Brady
- Nyaya Health, Bayalpata Hospital, Ridikot VDC, Achham, Nepal
- Division of Health Sciences, Montana State University, Bozeman, Montana, USA
| | - Selwyn Rogers
- Department of Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
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