TU5.4 ‘Learning lessons, inspiring change and driving improvements’ - A review of morbidity and mortality meetings in General and Vascular surgery

Abstract

Aim According to RCS/ASGBI guidance all surgeons should regularly attend Morbidity and Mortality meetings (M&Ms), as they are a key activity for reviewing the performance the team and ensuring quality of care. We aimed to review General and Vascular Surgery M&Ms at our site – are they in keeping with guidelines and can improvements be made? Methods A retrospective review of General and Vascular Surgery M&Ms was performed. Presentations were assessed against 12 key performance indicators (KPIs) as recommended by RCS/ASGBI. Following audit Cycle 1, a standardized M&M presentation proforma and an M&M outcome form were introduced, with subsequent second and third audit cycles completed. Results In comparison to Cycle 1, overall improvements were seen in 9/12 KPIs in both General and Vascular Surgery M&Ms. 100% compliance was demonstrated in both General and Vascular Surgery M&Ms in 7 KPIs. Improvements can still be made in the completion of Clavien-Dindo scoring, NCEPOD classification, as well as M&M outcome forms. Literature review discussions were not included in any General Surgery M&Ms in either cycle and in only 14% of Vascular Surgery cases. Conclusion Significant improvement in RCS/ASGBI compliance was demonstrated with the introduction of an M&M presentation proforma. Emphasis and encouragement should still be placed on the importance of literature reviews to promote learning, although we appreciate time limitations can have an impact on this. By improving the quality of M&Ms, surgical teams can learn lessons, inspire change and drive improvements.