Meeting attendees pose with a larger-than-life version of ACPs logo at the Ernest N Morial Convention Center in New Orleans Photo by Kevin Berne
Meeting attendees pose with a larger-than-life version of ACP's logo at the Ernest N. Morial Convention Center in New Orleans. Photo by Kevin Berne

The new, improved M&M

Morbidity and mortality conferences are starting to be seen more as a potential opportunity to address patient safety issues and reduce preventable errors than as education- and blame-oriented.

Whether from personal experience or popular culture, most physicians can imagine the old-fashioned morbidity and mortality (M&M) conference, and it's not necessarily a pleasant picture.

Dr Sponsler Photo by Kevin Berne
Dr. Sponsler. Photo by Kevin Berne

“Ultimately, I think no matter how much we progress, there's still some piece of a lot of us that think of M&M conferences as the single individual being put on the chopping block and it being about individual error,” said Kelly C. Sponsler, MD, associate professor of hospital medicine at Vanderbilt University Medical Center in Nashville, Tenn.

During an Internal Medicine Meeting session called “Morbidity and Mortality Conference 2018,” she offered tips on how to update the M&M to be a less uncomfortable and more valuable experience for clinicians and, ultimately, patients.

“We've started rebranding M&M conferences and seeing them a little bit less as just purely education- and blame-oriented and more as a potential opportunity to address patient safety issues and reduce preventable errors,” said Dr. Sponsler. “Most errors and adverse outcomes are not related to a single bad seed. It's typically a series of events, some that may be active failures, or it may just be the perfect storm of latent conditions.”

What and who

Identifying such events is a logical goal for an M&M. “Usually we're trying to focus on cases that have some sort of preventability component, and historically, and even now, I think, teaching value is a big piece of choosing a case,” she said.

Despite the name of the gathering, cases don't necessarily have to involve morbidity or mortality, she noted. “We want to capture near misses. Just because harm didn't occur doesn't mean there wasn't an error that is worthy of discussion,” Dr. Sponsler said. “Think about other outcomes like readmissions ... Are there some cases that highlight some deficiencies in documentation? Or are there cases about excess resource utilization that you can focus on?”

If suitable cases are available, an M&M conference can be focused on a theme, such as sepsis or falls. Such commonly encountered conditions are a better topic than clinical zebras, she suggested. “Especially in teaching institutions, we tend to want to present really good cases, really rare cases, rare outcomes, something that's kind of out of the blue. But I think we need to remember that most morbidity and mortality occurs in our usual patient population.”

It's also best to avoid cases that are more likely to lead to an old-fashioned blame session than a collective lesson. “When the case comes down to true individual error or intentional harm or something, that's not a good, productive discussion. There are other avenues for addressing those types of errors,” she said.

Suitable cases might come from voluntary reports by hospital staff, but deeper digging may also be necessary. “Only a subset of errors are reported. So a lot of institutions have started to rely on trigger tools, which include a manual screen of cases looking for adverse outcomes,” said Dr. Sponsler. The Institute for Healthcare Improvement Global Trigger Tool is one such resource, she said.

In addition to choosing cases, M&M organizers should set some ground rules. “You want to foster an environment of confidentiality. You want to avoid finger-pointing,” said Dr. Sponsler. “What happens in an M&M conference, in terms of the case details, stays in an M&M conference.”

Confidentiality should protect not only patients, but staff. “In my experience, a lot of times the members of the team who were involved in the case will speak up and say, ‘This was my patient,’ or ‘I was there,’” she said. “But that's not a requirement.”

It is appropriate to invite any staff involved in the case to the conference, Dr. Sponsler said. “We all know that medical care is provided in teams, so if you are discussing a patient case and an adverse outcome, why in the world would you fail to include a number of important members of the team?” she asked. It might be helpful to involve nurses, physicians from other specialties, pharmacists, or staff in less clinical roles. “There may be cases where someone from environmental services or patient transport or medical records has a role and a viewpoint and something to contribute,” she said.

Risk management and legal staff might also want to be notified about plans for an M&M, although the legal risks are often minimal, Dr. Sponsler explained. “A lot of individual states have some laws around peer review and statements that say, ‘We want you to have these forums. Anything that you are addressing in these forums is privileged and protected information.’”

Inviting administrators to an M&M can be helpful if the lessons of the M&M could or should lead to changes in hospital practice or procedure. “Clinical leadership or nonphysician administrators can help you ultimately move some of these projects forward,” said Dr. Sponsler.

The most difficult decision may be whether to invite patients or their family. “It's a little controversial,” she said. “We know generally that patient engagement can be associated with improved outcomes. Theoretically, there is a role for patients in these discussions about safety and adverse events.... There's not really any literature to say how this might be done and if it should be done.”

M&M conferences at Vanderbilt have occasionally involved patients or family, but only in very specific situations. “Usually it is a patient or family member who is also a medical center employee and has some clinical knowledge and is familiar with the process,” said Dr. Sponsler.

Format fixes

The format of an M&M is important to its functioning. “Unstructured design, nonstandardized presentations, inadequate discussion time, being talked at—those are things that are associated with lower satisfaction and core ratings. A lot of success stories have related to a redesign of M&M conferences to have a very specific agenda and timeline,” said Dr. Sponsler.

She offered an example of such a success from the literature. An M&M redesign at the University of Colorado was described in the September 2016 Academic Medicine. “They, at baseline, found that they had a lot of variability in their conference structure and that the focus tended to be on the medical and clinical aspects of the case, more than quality and safety,” said Dr. Sponsler.

To correct this, the organizers set a timed structure for the conferences, beginning with a five-minute introduction. “Importantly, one of the things they start out with is some information from last month's case. What were those action items? Where do we stand with that?” she said. Attendees are also reminded about confidentiality and the need to focus on systems thinking, as well as given some context for the upcoming case.

Then 20 minutes are spent on presentation of the case. “Generally, a timeline chronologic story makes the most sense, but this is something that you want to put some thought into: deliberately curating this case presentation in a way that is concise and objective,” said Dr. Sponsler.

The paper recommends following the case presentation with 30 minutes for analysis, but before the group discussion starts, it may be helpful to give the audience some additional information, Dr. Sponsler suggested.

“A lot of times there's a role for having a pause after the case presentation to review some clinical pearls, literature, and/or introduce some specific quality and patient safety concepts, typically by a content expert,” she said. “Assuming you have multiple different disciplines as part of your conference, it can provide a little bit of level-setting, so that all of the participants are on the same page, related to the medical aspects of the case, and also some of the basic quality and patient safety concepts.”

The group discussion should be actively led by a facilitator, who can keep an eye on the time and make sure the discussion is productive, focusing on potential solutions. It's good if the facilitator, or someone helping to lead the discussion, has some expertise in quality improvement (QI), suggested Dr. Sponsler.

“Introducing some QI tools can be helpful to help probe discussion,” she said, offering fishbone diagrams as one example. “This is probably one of the best tools to use as part of an M&M discussion.... I think this is a nice way to reinforce systems thinking.”

Pareto charts can be used to show how a number of factors contributed to an error but a few were most responsible for the effects. Similarly, the causes of an event can be identified using process maps, flow charts, and the “five whys” process. “Quite simply, you just keep asking why: Why did this happen?” Dr. Sponsler explained.

The M&M should end with a five-minute wrap up. “You want to close the conference with a summary and some sort of specific action items: What did we learn from this case? What are we going to do about it next?” she said.

Next steps might include the development of a project. “This can be a great opportunity for residents and fellows especially to partner with faculty on QI projects that can result in some scholarship and improve patient care,” Dr. Sponsler said.

She noted that M&M conferences generally can help academic programs meet their Accreditation Council for Graduate Medical Education core competencies. “All six of them you can hit on, but certainly the systems-based practice and the problem-based learning can really fall in nicely here,” she said. “A lot of times residents or chief residents or fellows may be engaged in actually preparing and presenting the case.”

Talk to action

Translating an M&M discussion into action is key, Dr. Sponsler said. She cited another example of successful M&M redesign, reported by researchers from Ottawa, Canada, in the June 2017 BMJ Quality & Safety.

The program developed a specific format for an M&M and, after a successful pilot, rolled it out to multiple clinical departments, with training, a guide, and a toolkit. “Before they did this, nothing really came out of the case discussions,” she said. “Afterwards, they were able to demonstrate a number of action items that then were pursued and moved into actual improvement projects.”

Hospitals should develop their own systems for taking action based on M&M findings, Dr. Sponsler suggested. “You really want to create a linkage between these conferences and the hospital quality experts and administrators that are accountable for some of these outcomes. Who owns the next steps? Who owns the action items?”

The answer to those questions could be a dedicated committee or team. Any action taken should also be reported back to the participants in the conferences, she recommended. “You need to be a little bit careful sometimes with websites and emails and newsletters, just in terms of not disseminating some of the sensitive patient information or some of the error parts of the case. But having some closure and feedback can really help engagement in these conferences going forward.”

In addition to reporting results, programs may want to find some way to keep track of the conferences themselves. “Is somebody centrally tracking all the different M&M conferences that are being held across the institution and aggregating some of these cases and figuring out how to prioritize some of the themes that are commonly surfacing? There's definitely a role here to have some sort of documentation or database,” she said.

Perhaps such documentation could build the evidence base for M&Ms, which is relatively weak right now, Dr. Sponsler reported. “There is not a lot of evidence that M&M conferences actually lead to improved patient care or a reduction in errors or adverse events. Of course, that's a linkage that can be hard to make,” she said. “On the other hand, there is some evidence that M&M conferences do produce some favorable education and quality and safety measures, typically around engagement of participants, attitudes, behaviors, some medical knowledge.”

The limitations of the research shouldn't discourage hospitalists from trying to organize and improve M&Ms, according to Dr. Sponsler. “The bottom line is even though it hasn't necessarily been proven, I think we can all agree there is some theoretical value to both education of participants and hopefully to patient care,” she said. “There is value in reflecting on errors, reflecting on our own performance, continuing to learn.”