The Morbidity, Mortality, and Improvement Conference: An Innovative, Action-Oriented Learning Space

Area of Science:

• Healthcare quality improvement
• Patient safety research
• Medical education

Background:

• Traditional morbidity and mortality conferences may lack focus on systems, action plans, and interprofessional engagement for adverse event analysis.
• There is a need for structured approaches to learn from adverse events and implement systemic improvements.

Purpose of the Study:

• To design and implement a novel conference format focused on learning from adverse events.
• To engage diverse staff in developing systems-oriented action items and ensure follow-through.
• To establish a closed-loop communication system for staff on implemented improvements.

Main Methods:

• A quarterly conference was designed involving interdisciplinary, interdepartmental staff reviewing adverse events.
• Interactive discussions identified root causes and system-level solutions.
• Actionable solutions were implemented and communicated in subsequent conferences.
• Attendee surveys assessed perceived impact on safety culture; monthly safety reports were tracked.

Main Results:

• Conference attendance increased by 157.5%.
• Participant-reported comfort in raising concerns and interprofessional teamwork improved to 100%.
• Positive shifts in learning culture (93.4%), clinical area changes (90.0%), and health system changes (96.7%) were reported.
• Monthly safety reports increased by 17.0%.

Conclusions:

• The morbidity, mortality, and improvement conference effectively enhanced safety attitudes, collaboration, and system design.
• This interactive, system-focused conference cultivates trust and transforms staff into safety change agents.
• The model demonstrates significant improvements in psychological safety and safety reporting within healthcare settings.