Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference
Barrett Cromeens1, Richard Brilli2, Kelli Kurtovic2
1Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.
Background/Purpose:
The M&M conference at Nationwide Children's Hospital (NCH) categorized failures as technical error or patient disease, but failure modes were never captured, action items rarely assigned, and follow-up rarely completed. In 2013 a QI-driven M&M conference was developed, supporting implementation of directed actions to improve quality of care.
Methods:
A classification was developed to enhance analysis of complications. Each complication was analyzed for identification of failure modes with subcategorization of root cause, a level of preventability assigned, and action items designated. Failure determinations from 11/2013-10/2014 were reviewed to evaluate the distribution of failure modes and action items.
Results:
Two-hundred thirty-seven patients with complications were reviewed. One-hundred thirty patients had complications attributed to patient disease with no individual or system failure identified, whereas 107 patients had identifiable failures. Eighty-five patients had one failure identified, and 22 patients had multiple failures identified. Of the 142 failures identified in 107 patients, 112 (78.9%) were individual failures, and 30 (21.1%) were system failures. One-hundred forty-seven action items were implemented including education initiatives, establishing criteria for interdisciplinary consultation, resolving equipment inadequacies, removing high risk medications from formulary, restructuring physician handoffs, and individual practitioner counseling/training.
Conclusions:
Development of a QI-driven M&M conference allowed us to categorize complications beyond surgical or patient disease categories, ensuring added focus on system solutions and a reliable accountability structure to ensure implementation of assigned interventions intended to address failures. This may lead to improvement in the processes of patient care.
Insights
A quality improvement (QI)-driven Morbidity and Mortality (M&M) conference improved patient care analysis by identifying failure modes and assigning actionable interventions. This system enhances accountability and focuses on system solutions for better outcomes.
Area of Science:
- Healthcare Quality Improvement
- Patient Safety
- Medical Error Analysis
Background:
- Traditional Morbidity and Mortality (M&M) conferences at Nationwide Children's Hospital (NCH) lacked structured failure mode capture and follow-through.
- Failures were broadly categorized as technical error or patient disease, limiting in-depth analysis.
- This led to infrequent assignment of action items and poor completion rates.
Purpose of the Study:
- To develop and implement a Quality Improvement (QI)-driven M&M conference.
- To enhance the analysis of patient complications by identifying specific failure modes and root causes.
- To establish a system for assigning and tracking actionable interventions to improve patient care quality.
Main Methods:
- A new classification system was developed to analyze patient complications.
- Each complication was assessed for failure modes, root causes, and preventability.
- Failure determinations from a one-year period (11/2013-10/2014) were reviewed to analyze failure modes and action items.
Main Results:
- Out of 237 patients with complications, 107 had identifiable failures.
- Of 142 identified failures, 78.9% were individual and 21.1% were system failures.
- 147 action items were implemented, including education, improved consultation criteria, equipment updates, medication formulary changes, and enhanced handoff procedures.
Conclusions:
- The QI-driven M&M conference enabled categorization of complications beyond simple disease or technical errors.
- It provided a structured approach to identify system failures and ensure accountability for interventions.
- This methodology is expected to improve patient care processes and outcomes.
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