One health system’s morbidity and mortality conference survey: a step on the journey to organizational high reliability

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Background: The goal of this study was to understand the state of morbidity and mortality conferences held throughout our health system. Assessment of current approaches is necessary for a journey toward organizational high reliability and an opportunity to reduce unnecessary variation in patient and process outcomes. Study Design: Forty-two anonymous surveys were distributed through the Health System’s Vice-chairs of Quality to those in the best position to answer questions. Answers from all departments and—where semi-autonomous—divisions were solicited. Categories, among others, included written guidelines, who presented, what events were chosen for presentation, and what was done with the data. Results: Forty-one surveys were returned. Seventeen departments or divisions have written guidelines as to which events should be reported. Twenty-two of the departmental or divisional conferences present selected cases, only 13 present all mortalities. Decisions on how events are classified are made most often by the director of Quality with 13 responses. There was no consensus on how best to enhance the clinical learning environment for residents and fellows. Conclusion: Opportunities identified by our survey to reduce practice variation include best practices for written guidelines and standardized classification formats for morbidity and mortality events. A mortality committee charged with event review and classification should be considered. Lastly, more effort should be made to enhance the clinical learning environment of trainees in event review and presentation.