The modern morbidity & mortality conference Greg Sacks, MD, MPH Robert Wood Johnson Clinical Scholars program Department of Surgery University of California, Los Angeles
History of M&M conference Earliest reference by Ernest Codman at Massachusetts General Hospital in early 1900s The End Result System 1935 Anesthesia Mortality Conference 1983 ACGME requires accredited residency programs to conduct weekly review of all complications and death Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Academic Medicine. 2002;77(10):1001 1006.
The M&M Pathway 1. Identify relevant cases Complications Interesting cases 2. High quality presentations M&M Conference Education Quality improvement 3. Ensure individual and system learning 4. Close the loop
Current challenges 1. Identification of complications Relies on voluntarily submission by resident 100% complications presented 2. Presentation Disorganized and fail to focus on complication 3. Learning from complications Inconsistent educational value 4. Quality improvement Absence of the important next step
1. Identify relevant cases Complications Interesting cases 2. High quality presentations M&M Conference Education Quality improvement 3. Ensure individual and system learning 4. Close the loop
How to identify complications? Old way: 1. Resident report 2. Attending request New way: NSQIP NSQIP QITI Incident reporting Risk management Electronic health record Other hospital committees Campbell, W. B. (1988). Surgical morbidity and mortality meetings. Annals of the Royal College of Surgeons of England, 70(6), 363.
1. Identify relevant cases Complications Interesting cases 2. High quality presentations M&M Conference Education Quality improvement 3. Ensure individual and system learning 4. Close the loop
Presenting complications SBAR framework Situation Background Assessment Recommendations Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 88(6), 824 830.
Presenting complications SBAR framework Situation Background Assessment Recommendations Statement of problem 1. Admitting diagnosis 2. Procedure performed 3. Complication Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 88(6), 824 830.
Presenting complications SBAR framework Situation Background Assessment Recommendations Relevant clinical information 1. Patient history 2. Details of operation 3. Hospital course 4. Management Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 88(6), 824 830.
Presenting complications SBAR framework Situation Background Assessment Recommendations Error analysis 1. What went wrong? 2. How did it go wrong? 3. Root cause analysis Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 88(6), 824 830.
Cause Analysis Root Cause Analysis Effect Individual factors Team factors Patient factors Did not use full body drape Nurse did not feel comfortable stopping procedure Immunosuppressed Central line infection Full body drape not in central line kit No checklist used Hospital purchases CL kit without appropriate sterile equipment Environment Rules/Policy Organization 12
Presenting complications SBAR framework Situation Background Assessment Recommendations Proposed actions 1. Literature review 2. Highlight learning point 3. Prevent further complications Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine, 88(6), 824 830.
1. Identify relevant cases Complications Interesting cases 2. High quality presentations M&M Conference Education Quality improvement 3. Ensure individual and system learning 4. Close the loop
Learning from complications Implementation of SBAR led to improvements in: Presenter satisfaction Presentation quality (especially background and assessment sections) Educational outcomes Mitchell, E. L., Lee, D. Y., Arora, S., Kenney-Moore, P., Liem, T. K., Landry, G. J., et al. (2013). Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study. Academic Medicine : Journal of the Association of American Medical Colleges, 88(6), 824 830.
1. Identify relevant cases Complications Interesting cases 2. High quality presentations M&M Conference Education Quality improvement 3. Ensure individual and system learning 4. Close the loop
Close the loop M&M Conference Quality improvement The Engine of Quality Improvement 1. How? When? Who? 2. List of problems
Conclusions 1. M&M conference is ideal venue for open discussion about areas for improvement 2. Multiple data sources can be used to identify cases for presentation 3. The SBAR format is useful to standardize presentations, improve audience learning, and inform quality improvement efforts