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The Morbidity and Mortality Assessment Tool (MMAT): Design and Proof of Concept
Tandis Soltani1, KeyYan Tsoi1, Aidan Charles1
1Surgical Residency Program, University of Central Florida College of Medicine/Hospital Corporation of America, Graduate Medical Education Consortium, Ocala, Florida; University of Central Florida, College of Medicine, Orlando, Florida.
Background:
Morbidity and Mortality Conference (MMC) is a traditional quality assessment tool among surgical residencies to evaluate complications within their care and to integrate and educate best practices. Unfortunately, it is difficult to validate and measure loop closure as a result of MMC. This may result in repeating past mistakes or worse, becoming a meeting of anecdotal experiences. The goal of this study is to present results from a morbidity and mortality assessment tool (MMAT) which provides a means of measuring and tracking factors related to those surgical complications discussed within the MMC.
Materials And Methods:
Three years of MMC presentations were organized into a database and further divided and organized into variables which included case by the class year of the presenting resident, service line, month the case was presented, and potential contributing factors. Contributing factors considered for each case were categorized as: Systems-Based, Direct Patient Care, and Interpersonal Communication. Contributing factors were assigned to cases by a review committee consisting of residents and faculty members.
Results:
The lack of knowledge, technical error, lack of experience, lack of supervision, failure to communicate with team members were present in greater than 10% of the presented cases. There was a "July Effect" in the Trauma service, where there was a statistically significant difference between the percentage of cases presented that involved Failure to Communicate errors when compared with the remainder of the year.
Conclusions:
MMAT allows longitudinal collection of data from each MMC to recognize patterns that facilitate improvements in systems of care and institutional memory.
Insights
A new Morbidity and Mortality Assessment Tool (MMAT) was developed to track surgical complications discussed in Morbidity and Mortality Conferences (MMC). This tool helps identify recurring issues and improve patient care by analyzing contributing factors.
Area of Science:
- Medical education
- Surgical quality improvement
- Healthcare systems analysis
Background:
- Traditional Morbidity and Mortality Conferences (MMC) in surgical residencies struggle with validating outcomes and preventing recurring errors.
- The anecdotal nature of MMC can hinder the integration and education of best practices.
- A need exists for a structured tool to measure and track factors contributing to surgical complications.
Purpose of the Study:
- To introduce and present results from a novel Morbidity and Mortality Assessment Tool (MMAT).
- To demonstrate MMAT's capability in measuring and tracking factors related to surgical complications discussed in MMC.
- To provide a data-driven approach to surgical quality assessment.
Main Methods:
- Three years of MMC presentations were compiled into a database.
- Data were categorized by resident year, service line, presentation month, and contributing factors (Systems-Based, Direct Patient Care, Interpersonal Communication).
- A review committee of residents and faculty assigned contributing factors to each case.
Main Results:
- Lack of knowledge, technical error, lack of experience, lack of supervision, and failure to communicate were identified in over 10% of cases.
- A "July Effect" was observed in the Trauma service, with a significant increase in "Failure to Communicate" errors during July.
- Analysis revealed specific patterns in error types and their frequency.
Conclusions:
- The Morbidity and Mortality Assessment Tool (MMAT) enables longitudinal data collection from MMC.
- MMAT facilitates the recognition of patterns to improve healthcare systems and institutional memory.
- This data-driven approach supports evidence-based improvements in surgical care.
