Cyclic workflow to improve implementation of learning points from morbidity and mortality meetings

Area of Science:

• Healthcare Improvement
• Patient Safety
• Medical Education

Background:

• Morbidity and Mortality Meetings (M&MMs) are crucial for learning from adverse events (AEs) to enhance patient care.
• Current M&MMs often suffer from ineffective follow-up, limiting their impact on patient safety.
• A novel strategy is needed to integrate M&MM outcomes into daily clinical practice.

Purpose of the Study:

• To evaluate the effectiveness of a cyclic workflow in improving the implementation of M&MM outcomes.
• To identify critical factors influencing the successful implementation of M&MM-derived improvements.

Main Methods:

• A prospective study utilizing a participatory action research (PAR) approach at a university hospital's gynecologic oncology department.
• Implementation of a cyclical workflow based on the Plan-Do-Check-Act (PDCA) cycle over 10 M&MMs.
• Observation of meetings and interviews with professionals, followed by thematic content analysis.

Main Results:

• 94.8% of tasks derived from M&MMs were successfully implemented using the PDCA cycle.
• Key success factors identified: organizational culture, motivation, commitment, communication, and skills.
• Regular workflow repetition and external reminders were vital for habit change and motivation.

Conclusions:

• Cyclical tools effectively support the implementation of M&MM improvement areas.
• An open, free-discussion culture within M&MMs fosters task commitment.
• Team participation and creating learning environments outside M&MMs promote engagement in improvement practices.