Not Your Dad s M & M: How to Restructure your Morbidity and. Learning Objectives

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1 Not Your Dad s M & M: How to Restructure your Morbidity and Mortality Conference to Teach and Model the Core Competencies R. Dobbin Chow, MD, FACP Good Samaritan Hospital of Maryland Charles Albrecht, MD, FACP JHU/Sinai Hospital Program in IM John Cmar, MD JHU/Sinai Hospital Program in IM Learning Objectives Understand how to organize the Morbidity and Mortality Conference to address the six core competencies. Understand how to effectively integrate the six dimensions of quality health care into the case discussion Understand how to foster an atmosphere during conference of collegiality, teamwork, and professionalism

2 Organization of Workshop I. Creating culture and environment - Albrecht (20 mins) II. Creating structure and organization - Chow (15 mins) III. Linking the core competencies to improvement in quality of care - Cmar (10 mins) IV. Case (45 mins)

3 If not for Washington, D.C., you wouldn t know where to find us. Section I: Creating Culture and Environment Charles R. Albrecht III,MD, FACP How is the culture of safety in your organization reflected in the conference? Is there a process to learn from mistakes? How can you make your conferences multidisciplinary? How do you strike the balance between education and problem solving?

4 II. Creating Structure and Organization Dobbin Chow, MD Program Director, Good Samaritan Hospital Residency Program in Internal Medicine Why do Internal Medicine Programs hold Morbidity & Mortality Conferences? The program must sponsor monthly conferences in which faculty members are involved. These must include: 1) a journal club and either a) clinical pathological conferences or b) clinical quality improvement (morbidity and mortality) conferences focusing on adverse clinical events on the teaching services. It should analyze the causes and consequences of each event, and should result in proposals for actions to avoid recurrence of similar events. ACGME Internal Medicine Program Requirement IV.C.2.c

5 Proposed New Program Requirements Residents must have the opportunity to participate in morning report, grand rounds, journal club, and morbidity and mortality (or quality improvement) conferences, all of which must involve faculty. A Historical Perspective Early 1900 s: M & M arose from surgical and anesthesia disciplines ACGME now mandates that general surgery residencies hold a M & M Conference on a weekly basis Developed wide spread acceptance among diverse training disciplines, including pediatrics, family practice, and surgical subspecialties Focus on the competencies of medical knowledge and patient care

6 Despite its longstanding legacy There is no uniformly accepted standard format Lack of uniform goals or conference objectives Poorly defined roles for presenters and audience members Missed opportunity to target the competencies of practice-based learning, system based practice, professionalism, and communication Anecdotal Experiences: The attendings seem to take pride in terrorizing and humiliating the resident who presents the case. Everyone hated to present - resident The few times that I had to present, I ended up in tears after the conference. I found out later that everyone else all cried in private afterwards. I took solace in the fact that it happened ed to everyone. e e -resident Everyone must understand that the same mistakes must not be made again in the future. These conferences are designed to ensure that everyone learns from their mistakes. - attending

7 M & M Conferences: An Opportunity Lost? Help meet the need for resident education in the areas of patient safety and practicebased learning Help meet society s mandate for physician accountability Become a venue for identifying and correcting errors in a medical system of care A Bridge Across the Quality Chasm? Recommendations: an increased reporting and study of errors, openness to discussion, and realization that errors result from system flaws, not character flaws. Institute of Medicine: Crossing the Quality Chasm. Washington, D.C. National Academy Press 2001

8 Defining Your M & M Conference 1. What are the overall guiding principles i for the M&MC M Conference for your institution? Samples of Guiding Principles Medicine is inherently difficult, and errors are inevitableit Errors are usually the result of a flawed system, and do not necessarily occur at a predictable rate. Input from multiple disciplines may result in unique and effective solutions

9 Samples of Guiding Principles An open discussion without retribution enhances future error reporting and thus promotes patient safety There are alternative venues to address individual deficiencies Confidential nature of the conference discussion Purpose is to share what we have learned from one experience to help others in the future Making the Guiding Principles Explicit State the principles at the outset of each conference Use guidelines to engender atmosphere of collegiality, critical reflection, selfeducation Guidelines serve to frame and codify the case discussion

10 What the M & M should not be: Used as a venue to present interesting cases Used only to meet accreditation goals of the institution Used as a method of remediation or for provision of feedback Creating Structure and Organization Frequency? enc How many cases per session? How are cases identified? Who moderates the session? Who presents the case?

11 Who Serves as Moderator? Orlander JD and Fincke BG. JGIM 2003; 18: % - Chief Resident 14% - Program Director 14% - Chief of Medicine 14% - Appointed faculty member 22% - Other Role of Moderator Serve as consistent leader Invite selected guests, based on nature of case Summarize findings and assign tasks based on recommendations Have authority to delegate responsibility and develop policy Maintain a neutral perspective and become an advocate for the institution as a whole, not for a sub-group

12 Challenges for the Moderator Create an atmosphere and style of objective criticism, but not persecution Create a safe environment that encourages disclosure, reflection, introspection, and collaboration Reinforce personal accountability by all parties Objectively evaluate quality of care, using available evidence as well as standards of care Foster development of creative solutions How are Cases Selected? Orlander JD and Fincke BG. JGIM 2003; 18: % - unexpected mortality 20% - unexpected morbidity 13% - unexpected error 34% - teaching value or availability of pathology

13 Methodology for Case Selection Cases should be recent and contemporary Nomination of and the selection process of cases should be transparent The process of nomination of cases should be announced at each conference to solicit new cases Risk management staff, faculty, residents, nurses, private attendings may all serve as sources of referral All referrals should be acknowledged, whether selected or not Pitfalls in the selection of cases Cases should not be selected on the basis of their educational value Cases should not be dismissed because of the potential to cause embarrassment or humiliation Gross mismanagement or incompetence should not be presented in this forum Cases of Near-misses can be insightful

14 Who Presents the Case? Orlander JD and Fincke BG. JGIM 2003; 18: % - Resident 21% - Moderator 10% - Chief Resident 2% - Attending of record 23% - Other 3. How is the Case Discussion Organized? JAMA 2003; 290(21): Organization of case discussion should be consistent and predictable Compared to Surgery M&M, IM M&M Conferences were less prone to discuss adverse events, errors causing an adverse event, deaths due to errors, and deaths in general IM M&M have less discussion of errors, attribution of errors as cause of event, recognition or acknowledgment of errors

15 Potential Reasons for Lack of Rigor in Addressing Errors Potential to provoke defensive responses by the treating physicians Fear of inducing legal action Desire to not cast blame or suspicion Tendency to view errors as physician flaws rather than system flaws Conclusion of M&M Conference Summarize discussion Identify needs for change in systems of care Delegate responsibility for investigating or developing plans Add progress report to the agenda of future meetings Identify educational needs that can be addressed through residency curriculum

16 Feedback and Reflection Solicit feedback from audience on the conference logistics, moderator, and case presenters Audience should comment on whether conference met stated objectives If resident presenter accepts responsibility, he or she will be vehicle for change Provide resident with opportunity for reflection by using M&M Presenter Form, and incorporate into resident s portfolio Future Innovations Use of simulation devices to recreate clinical i l scenarios Acad Emerg Med 2006; 13: Need to demonstrate that M&M Conferences can significantly reduce errors

17 III. Linking the Core Competencies to Improvements in Quality of Care John Cmar, MD APD, JHU/Sinai Hospital Residency Program in Internal Medicine

18 Morbidity and Mortality: The Matrix John Bingham, M.H.A., Director, Center for Clinical Improvement, Vanderbilt University Medical Center Doris Quinn, Ph.D., Director Quality Education and Measurement Center for Clinical Improvement

19 What are we trying to accomplish? AIMS FOR IMPROVEMENT -Safe -Effective -Patient Centered -Timely -Efficient i -Equitable Six IOM Aims For Improvement Safe: avoiding injuries to patients from the care that is intended to help them. Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

20 Six IOM Aims For Improvement Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy. Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

21 Healthcare Matrix: Care of Patient(s) with. IOM Aims ACGME Competencies SAFE 1 TIMELY 2 EFFECTIVE 3 EFFICIENT 4 EQUITABLE 5 PATIENT-CENTERED 6 Assessment of Care Patient Care 7 (Overall Assessment) Yes/No Medical Knowledge & Skills 8 (What must we know?) Interpersonal & Communication Skills 9 (What must we say?) Professionalism 10 (How must we behave?) System-Based Practice 11 (What is the process? On whom do we depend? Who depends on us?) Practice-Based Learning & Improvement 12 (What have we learned? What will we improve?) 2004 Bingham, Quinn Vanderbilt University Improvement Information Technology Essential Questions Was care for this patient as good as it could be? What improvements in the competencies of the resident and faculty and changes in the system of care would result in improved care for the next patient?

22 Example 51 yo with PMH of Schizophrenia, Type II DM, OSA presents with pleuritic chest pain for 2 days. Studies reveal new onset of bun 60, creatinine 5. The patient was admitted for acute on (likely) chronic renal insufficiency and aggressively hydrated with resolution of agitation and stabilization of creatinine at 2.6 by end of hospital day #2. The patient subsequently spiked a fever to 38.4 at 9am (hosp day#3) and a cross covering intern was called and documented continued pleuritic CP, new productive cough, 99% saturation, clear lungs, negative UA and no leukocytosis with a plan to check a chest x-ray to rule out pneumonia with no plan for antibiotics at that time. Example At 6pm the night float intern came to relieve the day intern. No mention or up-date was made on the sign-out of the above patient, including documentation of the fever or pending chest x- ray. At 5 am (day #4) the night float intern was contacted with fever of 39 degrees, respiratory rate of 28, and saturations of 82%. A second chest x-ray is ordered. The chest x-ray was reviewed on the computer showing bilateral lobar consolidations. The patient was started on broad spectrum antibiotics, intubated for resp distress and sent to the ICU where blood and sputum cultures subsequently grew MRSA. The patient was successfully weaned after 10 days in the ICU and discharged to pulmonary rehab on day 24.

23 IOM Aims ACGME Competencies Patient Care 7 (Overall Assessment) Yes/No Medical Knowledge & Skills 8 (What must we know?) Interpersonal & Communication Skills 9 (What must we say?) Professionalism 10 (How must we behave?) System-Based Practice 11 (What is the process? On whom do we depend? Who depends on us?) Practice-Based Learning & Improvement 12 (What have we learned? What will we improve?) Healthcare Matrix: Care of Patient(s) with. SAFE 1 TIMELY 2 EFFECTIVE 3 EFFICIENT 4 EQUITABLE 5 PATIENT-CENTERED 6????? Assessment of Care???? 2004 Bingham, Quinn Vanderbilt University?? Improvement Information Technology IOM Aims ACGME Competencies Patient Care 7 (Overall Assessment) Yes/No Medical Knowledge & NO Skills 8 (What must we know?) Interpersonal & Communication Skills 9 (What must we say?) Professionalism 10 (How must we behave?) System-Based Practice 11 (What is the process? On whom do we depend? Who depends on us?) Practice-Based Learning & Improvement 12 (What have we learned? What will we improve?) Healthcare Matrix: Care of Patient(s) with. SAFE 1 TIMELY 2 EFFECTIVE 3 EFFICIENT 4 EQUITABLE 5 PATIENT-CENTERED 6 Assessment of Care NO NO NO NO?? NO NO NO NO NO NO NO NO NO Improvement See patient. Sign outs. Second chest xray was wasteful. Review previous diagnostic studies prior to ordering new study Bingham, Quinn Vanderbilt University Information Technology

24 IOM Aims ACGME Competencies Patient Care 7 (Overall Assessment) Yes/No Interpersonal & Communication Skills 9 (What must we say?) Healthcare Matrix: Care of Patient(s) with. SAFE 1 TIMELY 2 EFFECTIVE 3 EFFICIENT 4 EQUITABLE 5 PATIENT-CENTERED 6 Assessment of Care NO NO NO NO NO NO Appropriate Early administration of Patient did not receive Medical evaluation of antibiotics is essential standard of care, much less patients with fever to prevent deterioration evidence based care. Knowledge & and hypoxia. from pneumonia. CA- Skills 8 MRSA must be included in differential (What must we know?) of severe progressive CAP. Essential Appropriate followup standardized and documentation signout using when called with Professionalism 10 (How must we behave?) System-Based Practice 11 (What is the process? On whom do we depend? Who depends on us?) SBAR. Appropriate face time during signout. Must be responsible for essential patient care followup. Signouts must be done with appropriate time for questions. Residents who must leave to abide to duty hours need effective relief from housestaff when caring for coding patients. changes in patients condition. Call attendings with any change in condition. Must be sure all acutely ill patients are cared for in a timely manner. Must balance professional responsibility. Additional studies were reordered and performed based on a lack of previous study being signed out. Other providers of patients, especially complex patients who may be unable to give a detailed history must be contacted. Patients with psychiatric disorders should receive the same thoughtful approach to differential diagnosis. p y g Senior Residents, All results/ studies are on Hospitalists, Chief Powerchart. Always Residents, Physicians review what has been Assistants are available done rather than to support patient care reordering without needs when residents reviewing. are overwhelmed. The patient s decision making capacity was never properly assessed. The patient was not educated on the care plan. Practice-Based Learning & Improvement 1 (What have we learned? What will we improve?) Standardized Handoff. Educate residents regarding chain of command and who to turn to when overwhelmed. Official Policy on Chain of command. Incorporating culture of safety, official statement from Program Director that asking for help is a sign of strength rather than weakness. Improvement Residents reeducated on increasing number of results on powerchart and on proper evaluation of radiologic studies on the system. Policy that a discussion must occur with providers of any patients coming from any facility where there is intimate knowledge of the patient including but not limited to day care centers. 1 Practice-based learning and improvement: that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvement in patient care.

25 JHU/Sinai Experience Guiding principles stated by program faculty Risk management or program personnel report back system changes from previous M & M 2-3 cases presented each month. Cases identified by variety of sources: risk management, residents, hospitalists, clinical leaders, charge nurses, pharmacy, patient safety officer, medication safety officer Cases reviewed by the presenting resident AND chief of medicine, APD, or hospitalist Presenting resident completes the matrix, meeting with chief of medicine or APD several days in advance to review Risk management attends, as do appropriate experts JHU/Sinai Experience Approximately 50% of M+M s are the result of handoffs or mis- Approximately 50% of M+M s are the result of handoffs or miscommunication Approximately 50% of M+M s are the result of missed diagnosis (anchoring, availability, attribution i.e. cognitive errors) Systems based practice is the most frequently cited competency. Professionalism is the least frequently cited. Safety is the most frequently cited IOM aim. Equitable is the least frequently cited aim.

26 CONFIDENTIAL: Sinai Hospital Department of Medicine Report on Mortality Patient MR#: Primary Diagnosis: Secondary Diagnoses: Immediate Cause of Death: Terminal Event: Service: Length of Stay: Refer for Morbidity and Mortality Conference Presentation: Yes / No If yes, core competency/ies to be addressed (circle all that apply)? Patient Care Medical Knowledge Practice-Based Learning and Improvement Professionalism Interpersonal and Communication Skills Systems Based Practice PLEASE RETURN TOTHE CHIEF RESIDENT WHEN COMPLETE This formcontains information that is confidential, privileged, and/or protected fromdisclosure under state and federal laws that deal with the privacy and security of medical information. If you received this formin error or through inappropriate means, please page the Medical Chief Resident on call immediately. Workshop: The Matrix Small groups no >10/group Review case: Feel free to infer specifics Each group will focus on at least 2 IOM aims Feel free to fill out more if time permits Left Room: Safe, Patient Centered Center Room: Effective, Efficient Right Room: Timely, Equitable

27 Learning Objectives Understand how to organize the Morbidity and Mortality Conference to address the six core competencies. Understand how to effectively integrate the six dimensions of quality health care into the case discussion Understand how to foster an atmosphere during conference of collegiality, teamwork, and professionalism

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