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

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

ABSTRACT

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

Using Concurrent Complication Reporting to Evaluate Resident Critical Thinking and Enhance Adult Learning

OBJECTIVE

Critical thinking and accurate case analysis is difficult to quantify even within the context of routine morbidity and mortality reporting. We designed and implemented a HIPAA-compliant adverse outcome reporting system that collects weekly resident assessments of clinical care across multiple domains (case summary, complications, error analysis, Clavien-Dindo Harm, cognitive bias, standard of care, and ACGME core competencies). We hypothesized that incorporation of this system into the residency program's core curriculum would allow for identification of areas of cognitive weakness or strength and provide a longitudinal evaluation of critical thinking development.

DESIGN

A validated, password-protected electronic platform linked to our electronic medical record was used to collect cases weekly in which surgical adverse events occurred. General surgery residents critiqued 1932 cases over a 4-year period from 3 major medical centers within our system. These data were reviewed by teaching faculty, corrected for accuracy and graded utilizing the software's critique algorithm. Grades were emailed to the residents at the time of the review, collected prospectively, stratified, and analyzed by post-graduate year (PGY). Evaluation of the resident scores for each domain and the resultant composite scores allowed for comparison of critical thinking skills across post-graduate year (PGY) over time.

SETTING

Data was collected from 3 independently ACGME-accredited surgery residency programs over 3 tertiary hospitals within our health system.

PARTICIPANTS

General surgery residents in clinical PGY 1-5.

RESULTS

Residents scored highest in properly identifying ACGME core competencies and determining Clavien-Dindo scores (p < 0.006) with no improvement in providing accurate and concise clinical summaries. However, residents improved in recording data sufficient to identify error (p < 0.00001). A positive linear trend in median scores for all remaining domains except for cognitive bias was demonstrated (p < 0.001). Senior residents scored significantly higher than junior residents in all domains. Scores > 90% were never achieved.

CONCLUSIONS

The use of an electronic standardized critique algorithm in the evaluation and assessment of adverse surgical case outcomes enabled the measure of residents' critical thinking skills. Feedback in the form of teaching faculty-facilitated discussion and emailed grades enhanced adult learning with a steady improvement in performance over PGY. Although residents improved with PGY, the data suggest that further improvement in all categories is possible. Implementing this standardized critique algorithm across PGY allows for evaluation of areas of individual resident weakness vs. strength, progression over time, and comparisons to peers. These data suggest that routine complication reporting may be enhanced as a critical thinking assessment tool and that improvement in critical thinking can be quantified. Incorporation of this platform into M&M conference has the potential to augment executive function and professional identity development.

Systematic Review of Morbidity and Mortality Meeting Standardization: Does It Lead to Improved Professional Development, System Improvements, Clinician Engagement, and Enhanced Patient Safety Culture?

OBJECTIVES

This systematic review sought to better understand the effect of standardized Morbidity and Mortality meetings (M&Ms) on learning, system improvement, clinician engagement, and patient safety culture.

METHODS

Three electronic databases were searched using a range of text words, synonyms, and subject headings to identify the major concepts of M&M meetings. Articles published between October 2012 (the end date of an earlier review) and February 2021 were assessed against the inclusion criteria, and thematic synthesis was conducted on the included studies.

RESULTS

After abstract and full-text review in Covidence, from 824 studies identified, 16 met the eligibility criteria. Studies were mostly surveys (n = 13) and evaluated effectiveness primarily from the perspectives of M&M chairs and participants, rather than assessment of objective improvement in patient outcomes. The most prevalent themes relating to the standardization of M&M processes were case selection (n = 15) and administration (n = 12). The objectives of quality improvement and education were equally prevalent (12 studies each), but several studies reported that these 2 objectives as conflicting rather than complementary. Clinician engagement, patient safety culture, and organizational governance and leadership were identified as facilitators of effective M&Ms.

CONCLUSIONS

There is insufficient evidence to guide best practice in M&Ms, but standardized structures and processes implemented with organizational leadership and administrative support are associated with M&Ms that address objectives related to learning and system improvement. Standardization of the structures and processes of M&Ms is perceived differently depending on participants' role and discipline, and clinician engagement is critical to support a culture of safety and quality improvement.

Defining a High-Quality and Effective Morbidity and Mortality Conference: A Systematic Review

Importance

Morbidity and mortality conferences (MMCs) are thought to advance trainee education, quality improvement (QI), and faculty development. However, there is considerable variability with regard to their completion.

Objective

To compile and analyze the literature describing the format, design, and other attributes of MMCs that appear to best advance their stated objectives related to QI and practitioner education.

Evidence Review

For this systematic review, a literature search with terms combining conference and QI or morbidity and mortality was performed in January 2022, using the PubMed, Embase, and ERIC (Education Resources Information Center) databases with no date restrictions. Included studies were published in English and described surgical or nonsurgical MMCs with explicit reference to quality or system improvement, education, professional development, or patient outcomes; these studies were classified by design as survey based, intervention based, or other methodologies. For survey-based studies, positively and negatively regarded attributes of conference design, format, and completion were extracted. For intervention-based studies, details of the intervention and their impact on stated MMC objectives were abstracted. Principal study findings were summarized for the other group. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Abstract screening, full-text review, and data extraction and analysis were completed between January 2022 and December 2022.

Findings

A total of 59 studies met appropriateness for study inclusion. The mean MERSQI score for the included studies was 6.7 (range, 5.0-9.5) of a maximum possible 18, which implied that the studies were of average quality. The evidence suggested that preparation and postconference follow-up regarding QI initiatives are equally as important as both (1) succinctly presenting case details, opportunities for improvement, and educational topics and (2) creating a constructive space for accountability, engagement, and multistakeholder discussion.

Conclusions and Relevance

These findings suggest that the published literature on MMCs provides substantial insight into the optimal format, design, and related attributes of an effective MMC. This systematic review provides a road map for surgical departments to improve MMCs in order to align their format and design with their principal objectives related to practitioner and trainee education, error prevention, and QI.

A Survey-Based Assessment of the Practices Governing Morbidity and Mortality Conferences and the Effects of the COVID-19 Pandemic

BACKGROUND

Morbidity and mortality (M&M) conferences are essential components for resident education and provide a valuable tool to improve patient safety and quality of care. M&M conferences help identify important gaps in safety and reduce avoidable events in future patient care. Active methods to improve the utilization of M&M conferences have been shown to enhance their educational value for residents, faculty and multidisciplinary teams in healthcare institutions.

OBJECTIVE

The purpose of this study was to use a survey-based methodology to assess how morbidity and mortality conferences are conducted in residency programs, including characteristics such as frequency, involvement of personnel and the effects of COVID-19.

METHODS

From February to October 2021, a validated 19 question survey was electronically distributed to residency program directors in anesthesiology, emergency medicine and general surgery, after a search for email addresses in the ACGME database. The survey was created and hosted on Google Forms.

RESULTS

A total of 125 of 713 program directors (17.5%) responded to the survey. Eighty-three percent of respondent programs reported mandatory participation for residents, with residents providing most of the presentations. Case presentations utilized various formats including SBAR, adverse event analysis and root cause analysis as the most common modalities. Though most programs reported no change in frequency of M&M conferences due to COVID-19, most respondents reported a shift to a virtual or hybrid platform.

CONCLUSION

M&M conferences are an important educational and quality improvement modality, and many residency directors changed practice to incorporate virtual platforms due to the COVID-19 pandemic to maintain uninterrupted educational sessions. Nonetheless, significant variation still exists in how these conferences are conducted between different institutions.

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.

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.

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

Background

Morbidity & Mortality (M&M) meetings are a critical component of clinical governance. They have the potential to improve patient outcomes, quality of care, attitudes towards patient safety and they contribute to the education of clinical staff. This study aimed to evaluate individual surgeons’ experience of these meetings, and to explore their perceived usefulness and barriers to open discussion of adverse outcomes.

Methods

Consultant general surgeons in London, United Kingdom, were invited to anonymously complete an online survey consisting of 18 key items.

Results

Invitations were sent to 323 consultant surgeons from 19 NHS Trusts. Responses were received from 109 (33.7%), of which 99 (90.8%) answered all key items. Seventy-two of 104 (69.2%) attend almost all or all M&M meetings. These were rated as being more conducive for learning than for service improvement (p = 0.001). On a scale of 1 to 10 (10 = fearless), 41 of 105 (39.0%) rated as ≤5 the fearfulness of legal or other negative repercussions resulting from open discussion of complications/mortalities. Ninety-eight respondents gave a median rating of 10 (IQR: 8–10) for willingness to talk openly about their complications/mortalities (10 = willing/able).

Conclusions

Many surgeons in London do not routinely attend M&M meetings, despite these occurring within ‘protected time’. There may be a willingness to talk openly about complications, though there exists a fear of litigation. The nature, content and learning potential of such open M&M discussions should be explored in future research.