A few years ago, the family care center affiliated with Mercy St. Vincent Medical Center's family medicine residency program in Toledo, Ohio, inadvertently administered an extra immunization to one of its pediatric patients. A subsequent investigation revealed a chain of documentation and system practice errors that ranged from incomplete progress notes to misfiled immunization records. That situation may have continued indefinitely were it not for the patient's resident physician, who suggested the case become the next morbidity and mortality (M&M) conference case study.
When residents began untangling the case, they found that the office was overburdened due to absorbing patients from nearby practices that had recently closed. Struggling just to keep up with the influx, the office had not had time to standardize the incoming new charts and was continuing to use whatever immunization form was on the chart. In addition to documentation omissions and errors, a progress note stating that the immunization had been given was misfiled and therefore inaccessible when the child returned for a subsequent visit.
“Every single backup and safety system we had failed,” said Julie Stausmire, CNS, a clinical nurse specialist in research and education for the residency program. “We looked back in the M&M and found out we had this huge mess that no one really knew existed.”
Dr. Stausmire and her team dissected the immunization case and went on to conduct a research project to test the effectiveness of computerized registries in improving immunization timeliness and accuracy. It was an example of how Mercy St. Vincent Medical Center and others have reinvented the M&M conference, which has traditionally focused on disease pathophysiology, to identify systemic problems with an eye toward improving quality of care and patient safety.
“At one point, M&M conferences were about ‘What did you see?’, ‘What did you do wrong?’ or ‘Let's look at the X-rays',” said Ms. Stausmire. “We decided to re-do M&Ms to look at the big picture—what are all the pieces that went into it [the bad outcome] and what can we do to make sure it doesn't happen again in the future?”
Analyzing errors through the matrix
The internal medicine M&M conference, typically led and organized by residents, has long been considered a valuable educational tool for reviewing cases involving morbidity or mortality. That educational focus remains, but increasingly the discussion has moved away from challenging presentations of disease or difficult medical management to thinking about the underlying causes of errors and what can be learned from them.
“The goal should be to create a safe environment for discussion of systems issues related to patient safety,” said Steven J. Kravet, FACP, who led M&Ms at Johns Hopkins Bayview's department of medicine as medical director for ambulatory services and deputy director for clinical activities (he is now president of Johns Hopkins Community Physicians in Maryland). “The whole concept is practice-based learning and improvement—you're holding up a mirror and you're reflecting in that mirror to try to improve.”
It can be challenging at first to keep the focus on systems as opposed to allowing a free-reign case discussion, said Dr. Kravet. To avoid the latter, it helps to deflect discussion away from individual errors and view the case through broad domains of care that influence quality, such as professionalism or communication.
In a 2006 Journal of General Internal Medicine paper on M&M conferences, Dr. Kravet and colleagues discussed how Johns Hopkins incorporated the M&M into its grand rounds schedule and organized the discussion around the Accreditation Council for Graduate Medical Education's (ACGME) six core competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.
Another useful framework for discussion is the Institute of Medicine's (IOM) six “aims for improvement”—safety, effectiveness, patient-centeredness, timeliness, efficiency and equity, said Dr. Kravet. Often, residency programs borrow from both systems by following the Healthcare Matrix®, developed by John W. Bingham, MHA, and Doris Quinn, PhD, at Vanderbilt University in Nashville (See sidebar, below).
The Healthcare Matrix® asks physicians to assess the quality of care provided according to the IOM aims and, if there was a lapse (i.e., the care was not timely), to determine which ACGME competencies contributed to the problem and examine what can be done to improve. Physicians should ask two fundamental questions about the episode of care, the developers noted in a 2005 paper published in the Joint Commission Journal on Quality and Patient Safety:
- Was care for this patient as good as it could be?
- What improvements in the competencies of the resident and faculty and changes in the system of care would result in improved care for the next patient?
Hospitalists at San Francisco General Hospital used the Healthcare Matrix® as a template for creating a simplified model for M&M conferences, said William Huen, MD, associate chief medical officer and medical director of quality management at San Francisco General, which is affiliated with the University of California, San Francisco. The hospital's “Anatomy of an M&M” faculty seminar “lets people see how M&Ms are different from the traditional conference from preparation to discussion. You have to create a learning climate with an explicit agenda and discussion points” related to quality improvement, said Dr. Huen.
M&M conferences usually last one hour and are held weekly, monthly or quarterly, depending on the institution. The tone is constructive rather than punitive, noted Jay D. Orlander, MD, associate chief of medicine for education and clinical affairs at VA Boston HealthCare System, which is affiliated with three Boston-area residency programs. “We're trying to understand the facts so we can improve in the future.”
For hospitalists, who often lead quality and safety initiatives at their institutions, M&Ms are a valuable way of collaborating with other clinicians on potential improvements and change.
“The M&M is a forum to talk not just about the cool medicine and complex decision making but about systems of care,” said Read G. Pierce, ACP Member, a hospitalist and assistant professor of clinical medicine at San Francisco VA Medical Center (SFVAMC), which is affiliated with University of California, San Francisco. “It's a place to identify weaknesses in the system or have a space to talk about medical errors with an interdisciplinary group of colleagues.”
At SFVAMC, Dr. Pierce helped focus a recent M&M conference on the case of a patient who died en route while being transferred from a remote community hospital to San Francisco. SFVAMC cares for many patients who need complex medical care and procedures, yet live far away and get primary care near their homes. If such patients become very sick, or have complications related to treatments rendered in San Francisco, they may need to be transferred quickly from small hospitals with limited resources to SFVAMC, a tertiary center.
The M&M conference triggered formation of a multidisciplinary working group to look at whether SFVAMC was using a reasonable algorithm to decide when patients in remote parts of the network should come to San Francisco as opposed to a closer facility, he said. The case illustrates how the M&M is adding to SFVAMC's “spectrum of quality improvement,” which also includes root cause analysis, peer review and other quality-oriented committees, he added.
Without a framework, such as the Healthcare Matrix®, M&Ms often get bogged down in discussions of interesting disease presentations or complex medical management, Dr. Kravet warned. “The Matrix forces us to ask questions like, ‘Was the care safe, timely and equitable?’ You go through a series of questions to challenge what could have gone wrong.”
For example, one M&M case at Johns Hopkins involved a heavy smoker with lung disease and emphysema who was admitted to the hospital on the advice of his pulmonologist. A transtracheal oxygen catheter was inserted but had to be removed for cleaning when it filled with mucus. Physicians had difficulty replacing the catheter, and subsequent attempts at intubation and emergency tracheotomy failed. The patient later died due to cardiac arrest.
The case initially prompted a discussion of emphysema and the use of catheters, said Dr. Kravet. But, using the Matrix as a guide, the group eventually closed in on several problems related to core competencies, such as medical knowledge (lack of familiarity with tracheal catheters) and professionalism (is there an obligation to reserve this kind of therapy for candidates with less challenging issues?).
Digging deeper to discover what led to an error or bad outcome often leads to uncovering system problems that no one knew existed, and provides opportunities for system improvement. In one case in Mercy's hospital system, a critical value INR (international normalized ratio) for a patient on warfarin was initially missed—and the patient untreated—due to different measurable ranges of INR values between two institutions. The M&M conference led to developing a list of diagnostic results where the measurable range was different, and to standardizing the results of these tests. Where lab values could not be standardized, the lab director developed a list warning that the results were not the same between institutions, and compared normal and abnormal values for each, said Ms. Stausmire.
One case discussed at an M&M conference at VA Boston HealthCare triggered questions about whether interim measures should be taken before calling a code and mobilizing an entire team, said Dr. Orlander. The discussion eventually led to the creation of smaller rapid response teams that have helped reduce the number of cardiac arrests and facilitated transitions to the ICU, he said.
“When you put a bunch of people in the same room with similar goals who are bright and creative, people see different things,” observed Dr. Orlander. “What is the resident struggling with in the middle of the night? What is the nurse dealing with? Leaders making decisions aren't always there in the trenches. M&Ms put processes in place that accommodate the reality of the situation on the ground.”