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Published on: August 5, 2020

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised

M L Bechtold1, S Scott, K Nelson

  • 1Department of Internal Medicine, School of Medicine, University of Missouri Health Care, University of Missouri-Columbia, Columbia, Missouri, USA

Quality & Safety in Health Care
|December 7, 2007
PubMed
Abstract

Insights

Redesigning morbidity and mortality conferences (MMCs) improved patient safety by focusing on system issues, not individual blame. This enhanced quality of care and fostered a safe environment for improvement discussions.

Area of Science:

  • Medical Education
  • Patient Safety
  • Healthcare Quality Improvement

Background:

  • Morbidity and Mortality Conferences (MMCs) are crucial for analyzing adverse events but can be hindered by a focus on individual actions, potentially impeding the identification of systemic issues.
  • A culture of blame or shame can interfere with the effective analysis of adverse events and the implementation of necessary system improvements.

Purpose of the Study:

  • To redesign the internal medicine Morbidity and Mortality Conference (MMC) to emphasize patient safety principles and system-based interventions.
  • To foster a culture that distinguishes between blame and patient safety, identifies quality gaps, and promotes root cause analysis for adverse events.

Main Methods:

  • An interdisciplinary team modified the MMC format to focus on patient safety and system-based practice interventions.
  • Participant attitudes toward patient safety and conference redesign were assessed using pre- and post-intervention surveys.
  • Root cause analysis was performed for each adverse event, followed by discussions on system interventions to prevent recurrence.

Main Results:

  • 121 system improvement recommendations were generated, with 39 pursued and 23 implemented.
  • Participant surveys indicated positive shifts in attitudes towards patient safety, with 11 of 14 responses changing in the desired direction.
  • Average attendance at the modified conference increased significantly, from 41 to 50 participants (p<0.03).

Conclusions:

  • The redesigned Patient Safety MMC (PSMMC) successfully initiated quality improvements in patient care.
  • The PSMMC fostered a safe and nurturing environment, enhancing participants' ability to address adverse events and improve care.
  • The intervention demonstrated that MMCs can be effectively modified to promote patient safety without negatively impacting attendance or attitudes.

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