House staff–led interdisciplinary morbidity and mortality conference promotes systematic improvement

Tignanelli, Christopher J.; Embree, Genevieve; Barzin, Amir

doi:10.1016/j.jss.2017.02.065

Cited by 24 publications

(23 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…However, standardization of case selection and structured presentations can increase participation, educational value and the perception of an increased impact on future patient care [21, 22]. Refocusing M&M meetings on Quality Improvement (QI) education can transform them into a source of QI projects and help to ‘close the loop’ [23, 24], deemed crucial objectives of the modern M&M meeting [25], while satisfying the ACGME’s recent ‘Common Program Requirement’ for QI education in the United States [26].…”

Section: Discussionmentioning

confidence: 99%

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

et al. 2019

View full text Add to dashboard Cite

Background Morbidity & Mortality (M&M) meetings are a critical component of clinical governance. They have the potential to improve patient outcomes, quality of care, attitudes towards patient safety and they contribute to the education of clinical staff. This study aimed to evaluate individual surgeons’ experience of these meetings, and to explore their perceived usefulness and barriers to open discussion of adverse outcomes. Methods Consultant general surgeons in London, United Kingdom, were invited to anonymously complete an online survey consisting of 18 key items. Results Invitations were sent to 323 consultant surgeons from 19 NHS Trusts. Responses were received from 109 (33.7%), of which 99 (90.8%) answered all key items. Seventy-two of 104 (69.2%) attend almost all or all M&M meetings. These were rated as being more conducive for learning than for service improvement ( p = 0.001). On a scale of 1 to 10 (10 = fearless), 41 of 105 (39.0%) rated as ≤5 the fearfulness of legal or other negative repercussions resulting from open discussion of complications/mortalities. Ninety-eight respondents gave a median rating of 10 (IQR: 8–10) for willingness to talk openly about their complications/mortalities (10 = willing/able). Conclusions Many surgeons in London do not routinely attend M&M meetings, despite these occurring within ‘protected time’. There may be a willingness to talk openly about complications, though there exists a fear of litigation. The nature, content and learning potential of such open M&M discussions should be explored in future research.

show abstract

Section: Discussionmentioning

confidence: 99%

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

et al. 2019

View full text Add to dashboard Cite

show abstract

“…[ 27 , 28 ] Like the EFCs, the mortality and morbidity conferences can lead to the implementation of improvement action plans. [ 29 , 30 ] Their contribution to fostering teamwork and enhancing the safety culture of healthcare professionals has been acknowledged. [ 27 , 28 , 31 , 32 ]…”

Section: Discussionmentioning

confidence: 99%

Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments

et al. 2018

View full text Add to dashboard Cite

BackgroundThe experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis (RCA) within the team.ObjectivesTo investigate the functioning of EFCs in the departments of a large university-affiliated hospital in France and to consider its potential contribution to the management of patient safety.MethodsCross-sectional, observational study, based on an analysis of the documents produced by the EFCs for 1 year. Data were collected independently by two investigators in meeting minutes, adverse event reports and event analysis reports.ResultsThe study included all 20 EFCs operating in the hospital's medical departments. During the study year, committees held 164 meetings, reviewed 1707 adverse events, conducted 91 event analyses and decided on 206 corrective actions. The median number of corrective actions adopted by each EFC was five actions (range, 0–62). A root cause analysis (RCA) was present in 76% of the analysis reports, and these analyses were complete in only 23% of the reports. There was also a lack of planning corrective actions: an implementation deadline was only defined in 26% of the actions.ConclusionsHealthcare professionals adhered to the system-based approach to patient safety, but we observed difficulties in holding regular meetings and deviations from the theoretical framework. These findings confirm the difficulties of practicing RCA in the healthcare setting. Nevertheless, EFCs can be vectors of safety culture and teamwork.

show abstract

“…However, the recurring theme yielded from the literature is that there should be a standardized method for case selection [6]. There should also be a mandatory reporting system in place, wherein cases are selected from this repository outlining systems failures with potentially preventable outcomes [5][6][7][8][9][10]. Studies to date stress the importance of not merely presenting a depiction of weird and wonderful cases, or cases in which death could be attributable solely to the disease process itself [9].…”

Section: Case Selectionmentioning

confidence: 99%

“…One study advocated for the use of medical residents to receive assignment of a QI initiative stemming from MMC. It would then be their responsibility to implement the plan, seek assistance from other providers, and delegate tasks as necessary [7]. Participation in MMC should be sought from the hospital's QI department to aid in planning and implementation.…”

Section: Identification and Implementation Of Qi Initiativesmentioning

confidence: 99%

“…In a prospective observational study, Bal et al [19] noted that while 91% of MMCs observed identified issues in the cases presented, a structured method for identification was used in less than 10%. Comparatively, by switching MMC from an education focus to that of QI, Tignanelli et al [7] found that systems-based improvement strategies were identified in 73% of cases and that 82% of the proposed QI projects were successfully initiated. Similarly, a Canadian study implemented their own structured MMC model based on the three identified principles across disciplines in a single center and found 45 policy changes after the model was implemented, which was a stark contrast to zero that were implemented previously [24].…”

Section: Strengthsmentioning

confidence: 99%

See 1 more Smart Citation

Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review

Churchill

Murphy

Smith

2020

Cureus

View full text Add to dashboard Cite

House staff–led interdisciplinary morbidity and mortality conference promotes systematic improvement

Cited by 24 publications

References 18 publications

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

Morbidity and mortality meetings to improve patient safety: a survey of 109 consultant surgeons in London, United Kingdom

Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments

Quality Improvement Focused Morbidity and Mortality Rounds: An Integrative Review

Contact Info

Product

Resources

About