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Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department
Conor McDonnell1, Ronald M Laxer, W Lawrence Roy
1Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto. conor.mcdonnell@sickkids.ca
Background:
The concept of the morbidity and mortality (M&M) review is almost 100 years old, yet no standards describe "good practice" of M&M in clinical departments. Few reports measure output and impact of M&M reviews. The M&M activities were developed in a university-affiliated pediatric anesthesia department as part of a departmental quality improvement (QI) initiative. The process was designed to identify problems within the M&M program and to introduce interventions and actions to increase the program's efficiency and impact.
Methods:
Through a series of interviews and consultation with hospital management, existing problems and inefficiencies were identified, a framework for developing the M&M program was established, and reportable outcome measures, such as increased meeting attendance, participation, self-reporting, and change to practice, were developed. Through appointment of specific M&M personnel, appointment ofa specific departmental M&M coordinator, meeting more regularly, stressing the review of system errors and close calls, and encouraging anonymous reporting, the department's M&M activities were redesigned.
Results:
From the (July 1) 2001-(June 30) 2006 to (July 1) 2006-(June 30) 2009 periods, case reviews and case presentations increased from a mean of 1.9 to 3.4 cases presented per M&M meeting. Meeting attendance increased from a mean of 5.1 to 25, and self-reporting from a mean of 22% of all safety reports received to 40%. Findings and recommendations were effectively disseminated throughout the department and hospital, reflecting the unique structure of the M&M program and personnel's efforts.
Discussion:
M&M QI with respect to data gathering, case review, and ongoing medical education is an efficient way to demonstrate quality assurance and creative professional development.
Insights
Implementing a quality improvement initiative for morbidity and mortality (M&M) reviews in a pediatric anesthesia department significantly enhanced M&M program efficiency and impact. This led to increased case reviews, attendance, and self-reporting, demonstrating effective quality assurance.
Area of Science:
- Anesthesiology
- Quality Improvement
- Healthcare Management
Background:
- Morbidity and mortality (M&M) reviews are a long-standing practice, yet standardized "good practice" guidelines are lacking.
- Few studies quantify the output and impact of M&M reviews in clinical settings.
- A pediatric anesthesia department initiated a quality improvement (QI) project to refine its M&M program.
Purpose of the Study:
- To identify and address inefficiencies within the existing M&M program.
- To implement interventions to enhance the program's efficiency and impact.
- To establish measurable outcomes for the M&M program.
Main Methods:
- Conducted interviews and consultations with hospital management to identify problems.
- Developed a framework for M&M program enhancement and defined outcome measures.
- Appointed dedicated M&M personnel and a coordinator, increased meeting frequency, focused on system errors and close calls, and encouraged anonymous reporting.
Main Results:
- Mean case reviews per meeting increased from 1.9 to 3.4.
- Mean meeting attendance rose from 5.1 to 25 participants.
- Self-reporting of safety incidents increased from 22% to 40% of all safety reports.
Conclusions:
- Morbidity and mortality (M&M) quality improvement (QI) initiatives effectively enhance data gathering, case review, and medical education.
- These QI efforts demonstrate robust quality assurance and foster professional development.
- The redesigned M&M program proved efficient in disseminating findings and recommendations throughout the department and hospital.