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Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study
Erica L Mitchell1, Dae Y Lee, Sonal Arora
1Division of Vascular Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon 97239, USA. mitcheer@ohsu.edu
Purpose:
Surgical morbidity and mortality conferences (M&MCs) provide surgeons with an opportunity to confront medical errors, discuss adverse events, and learn from their mistakes. Yet, no standardized format for these conferences exists. The authors hypothesized that introducing a standardized presentation format using a validated framework would improve presentation quality and educational outcomes for all attendees.
Method:
Following a review of the literature and the solicitation of experts' opinions, the authors adapted a validated communication tool-the SBAR (Situation, Background, Assessment, Recommendations) framework. In 2010, they then introduced this novel standardized presentation format into the surgical M&MCs at the Oregon Health & Science University. The authors assessed three outcome measures--user satisfaction, presentation quality, and education outcomes--before and after implementation of their standardized presentation format.
Results:
Over the six-month study period, residents delivered 66 presentations to 197 faculty, resident, and medical student attendees. Attendees' performance on the multiple-choice questionnaires improved after the intervention, indicating an improvement in their knowledge. Presentation quality also improved significantly after the intervention, according to evaluations by trained faculty assessors. They noted specific improvements in the quality of the Background, Assessment, and Recommendation sections.
Conclusions:
The M&MC plays a pivotal role in educating residents and improving patient safety. Standardizing the M&MC presentation format using an adapted SBAR framework improved the quality of residents' presentations and attendees' educational outcomes. The authors recommend using such a standardized presentation format to enhance the educational value of M&MCs, with the goal of improving surgeons' knowledge, skills, and patient care practices.
Insights
Standardizing surgical morbidity and mortality conferences with the Situation, Background, Assessment, and Recommendations (SBAR) framework improved presentation quality and attendee knowledge. This enhances surgical education and patient safety.
Area of Science:
- Medical Education
- Surgical Conferences
- Patient Safety
Background:
- Surgical morbidity and mortality conferences (M&MCs) are crucial for learning from errors.
- Currently, no standardized format exists for M&MCs.
- A standardized approach may improve educational outcomes.
Purpose of the Study:
- To test if a standardized presentation format improves M&MC quality and educational outcomes.
- To evaluate the impact of a validated framework on surgical conference presentations.
Main Methods:
- Adapted the Situation, Background, Assessment, and Recommendations (SBAR) framework.
- Implemented the SBAR format in surgical M&MCs at Oregon Health & Science University.
- Assessed user satisfaction, presentation quality, and educational outcomes before and after implementation.
Main Results:
- Attendee knowledge improved, as evidenced by better questionnaire scores.
- Presentation quality significantly improved, particularly in the Background, Assessment, and Recommendation sections.
- The intervention led to enhanced educational value for attendees.
Conclusions:
- Standardizing M&MC presentations with the SBAR framework enhances educational value.
- Improved presentation quality and attendee knowledge contribute to better patient safety.
- The SBAR framework is recommended for improving surgical M&MCs.
