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

Goals of Morbidity and Mortality meetings in paediatric acute care. A qualitative case study

Morbidity and Mortality meetings are conducted in varied clinical contexts including paediatrics. Widely cited as an educational or quality improvement tool, the reality is more complex. In this qualitative study, the aim was to explore the perceived goals of the paediatric acute care Morbidity and Morbidity meeting. This study used semi-structured interviews and observation within a qualitative case study methodology. Data were collected in a large paediatric quaternary hospital. Analysis generated themes related to meeting observations and the participant's interpretation of meeting goals. A total of 44 interviews were conducted with 14 nurses, 29 doctors, and 1 allied health professional. Thirty-two meetings in six clinical departments were observed. Two themes were developed: complex and nuanced goals; and tensions and contest between and within goals. Meeting goals to evaluate care, learn, support, adhere, and change and respond were sometimes in competition and had varied interpretations. Morbidity and Mortality meetings in this setting are valued and occupy a complex role which reaches beyond identification of measurable patient safety interventions. Understanding goals more fully can lead to optimised conduct and meaningful measurement of efficacy. The strength in these meetings may be the way they promote an embedded safety culture, and an informed and skilled workforce.

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

OBJECTIVE

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

REVIEW METHODS USED

The study utilised scoping review methodology.

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

Kolb Meets Quality: Applying Learning Theory to a Process Improvement and Safety Curriculum

The healthcare landscape is changing, and the Accreditation Council for Graduate Medical Education has recognized the importance of training our physician workforce to demonstrate competency in quality, safety, and process improvement. In the renewal of our quality improvement and patient safety curriculum, we set out to create an impactful and relevant course of study using adult learning theories as a scaffold to design the curriculum and inform our teaching methods. In this Perspective, we describe a few key learning theories and demonstrate how we have used them in the teaching of quality improvement and patient safety concepts. Our intent was to create a curriculum that could equip the next generation of physicians with the knowledge, skills, and attitudes they will need to adapt to the changes they face in practice and improve their work environments.

Residents, Responsibility, and Error: How Residents Learn to Navigate the Intersection

PURPOSE

As a competency of Canadian postgraduate education, residents are expected to be able to promptly disclose medical errors and assume responsibility for and take steps to remedy these errors. How residents, vulnerable through their inexperience and hierarchical team position, navigate the highly emotional event of medical error is underexplored. This study examined how residents experience medical error and learn to become responsible for patients who have faced a medical error.

METHOD

Nineteen residents from a breadth of specialties and years of training at a large Canadian university residency program were recruited to participate in semistructured interviews between July 2021 and May 2022. The interviews probed their experience of caring for patients who had experienced a medical error. Data collection and analysis were conducted iteratively using a constructivist grounded theory method with themes identified through constant comparative analysis.

RESULTS

Participants described their process of conceptualizing error that evolved throughout residency. Overall, the participants described a framework for how they experienced error and learned to care for both their patients and themselves following a medical error. They outlined their personal development of understanding error, how role modeling influenced their thinking about error, their recognition of the challenge of navigating a workplace environment full of opportunities for error, and how they sought emotional support in the aftermath.

CONCLUSIONS

Teaching residents to avoid making errors is important, but it cannot replace the critical task of supporting them both clinically and emotionally when errors inevitably occur. A better understanding of how residents learn to manage and become responsible for medical error exposes the need for formal training as well as timely, explicit discussion and emotional support both during and after the event. As in clinical management, graded independence in error management is important and should not be avoided because of faculty discomfort.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

•

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

•

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

•

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

•

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

A SURVEY OF INTERVENTIONAL RADIOLOGISTS REGARDING THE USE OF MORBIDITY AND MORTALITY CONFERENCING IN DEPARTMENTAL QUALITY IMPROVEMENT PROGAMS

PURPOSE

Investigate the degree to which Morbidity and Mortality (M&M) conferencing is utilized in Interventional Radiology (IR), identify impediments to its adoption, and assess the experience of those using this tool.

MATERIALS AND METHODS

Members of the Society of Interventional Radiology (SIR) were offered a 10-question survey of practices and experiences regarding M&M conferencing within their Quality Assessment (QA) programs.

RESULTS

Among 604 respondents, 37.8% were university-based practitioners and 60% from outside of university practices. 43% of respondents reported practicing 100% IR, with 28.5% practicing 75-99% and 11% practicing IR less than 50% of the time. The use of M&M conferencing was significantly greater in university practices (90.7%) than in non-university practices (37.1%) and among practitioners performing at least 75% IR (71.2%) than among those practicing less than 75% (28.8%). Conferences were held monthly (66.6%) or more often and the majority (56%) of the events identified were scored using the SIR severity score. Roughly 20% of M&M conferences were multidisciplinary, shared most commonly with vascular surgery. The reasons cited for not using M&M included lack of time and the logistical challenges of the process. However, among those who participate in M&M conferences, the QA goals of the conference were met at very high rates.

CONCLUSIONS

M&M conferencing is well established in university IR programs and among full-time practitioners, but much less so elsewhere. For those sites that do not utilize M&M conferencing, there may be considerable benefit to addressing the obstacles that are limiting their implementation of this tool.

Quality of Heart Failure Care in the Intensive Care Unit

Patients with heart failure (HF) who are seen in an intensive care unit (ICU) manifest the highest-risk, most complex and most resource-intensive disease states. These patients account for a large relative proportion of days spent in an ICU. The paradigms by which critical care is provided to patients with HF are being reconsidered, including consideration of various multidisciplinary ICU staffing models and the development of acute-response teams. Traditional HF quality initiatives have centered on the peri- and postdischarge period in attempts to improve adherence to guideline-directed therapies and reduce readmissions. There is a compelling rationale for expanding high-quality efforts in treating patients with HF who are receiving critical care so we can improve outcomes, reduce preventable harm, improve teamwork and resource use, and achieve high health-system performance. Our goal is to answer the following question: For a patient with HF in the ICU, what is required for the provision of high-quality care? Herein, we first review the epidemiology of HF syndromes in the ICU and identify relevant critical care and quality stakeholders in HF. We next discuss the tenets of high-quality care for patients with HF in the ICU that will optimize critical care outcomes, such as ICU staffing models and evidence-based management of cardiac and noncardiac disease. We discuss strategies to mitigate preventable harm, improve ICU culture and conduct outcomes review, and we conclude with our summative vision of high-quality of ICU care for patients with HF; our vision includes clinical excellence, teamwork and ICU culture.

Rapid Mortality Review in the Intensive Care Unit: An In-Person, Multidisciplinary Improvement Initiative

BACKGROUND

Significant resources have been allocated to decreasing the number of preventable deaths in hospitals, but identifying preventable factors and then leveraging them to effect system-wide change remains challenging.

OBJECTIVE

To determine the ability of a novel in-person, multidisciplinary "rapid mortality review" process to identify deaths that are preventable and action items that lead to improvements in care.

METHODS

Rapid mortality review sessions were conducted weekly for patients who died in the medical intensive care unit. Patient data and clinician opinions regarding preventable deaths were discussed and recorded. Bivariate analyses were done to detect associations between case variables and the formation of an action item.

RESULTS

From 2013 to 2018, 542 patient deaths were reviewed; of those, 36 deaths (7%) were deemed potentially preventable. Facilitators identified issues in 294 cases (54%). A total of 253 action items were identified for 175 cases (32%); 60% of those action items were subsequently completed and led to tangible systemic change in 29 instances (11%). Action items were more likely to be identified for patients who had not been receiving comfort care (P < .001), for patients who had received cardiopulmonary resuscitation (P < .001), when the treatment team (P < .001) or the rapid mortality review facilitator (P < .001) had care-related concerns, and when the patient's death had been preventable (P < .001).

CONCLUSIONS

Even in settings with low reported rates of preventable deaths, an in-person multidisciplinary mortality review can successfully identify areas where care can be improved, leading to systemic change.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reuniones de morbilidad y mortalidad, ¿una estrategia de aprendizaje?

Las reuniones o conferencias de morbilidad y mortalidad (M&M), una práctica común en todo el mundo, buscan evaluar los eventos adversos y las complicaciones relacionadas con la atención médica, desde una perspectiva académica y considerando un mejoramiento en la calidad de la atención hospitalaria. Sin embargo, en nuestro país, su ejecución es un desafío metodológico debido a la dificultad para su conceptualización, implementación, evaluación de su efectividad y utilidad como herramienta educativa; al estar carente de una estructura formalizada que considere estos temas. El objetivo de este trabajo es evaluar su papel desde una perspectiva académica individual e institucional, considerando diferentes teorías y modelos que podrían apoyar el M&M (teoría del aprendizaje experimental, teoría de la actividad en el aprendizaje sociocultural, cultura justa, teoría de la seguridad del modelo y teoría de la segunda víctima), con el fin de responder la pregunta: ¿son las reuniones de M&M una estrategia de aprendizaje? 

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine

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.