Turning Mortality Discussions Into Process Improvements.

Abstract

The Morbidity and Mortality (M&M) conference is a traditional forum that provides residents with an opportunity to discuss and analyze medical errors. On a national level, M&M conferences appear to be increasing focus on systems of care and plans for process improvements. Unfortunately, academic discussions and hypothetical plans that occur during the M&M conferences often are not translated into actionable improvement plans. Without designated stakeholders to serve as a driving force to connect the academic discussions to a multidisciplinary forum, mortality reviews may not lead to process improvements or change in practice. In order for M&M conferences to lead to actionable plans, Stony Brook Internal Medicine Residency Program has established a multidisciplinary forum that is specifically tasked with creating process improvement projects stemming from M&M discussions.In an effort to focus on systems change and process improvement, the residency program restructured the content of the M&M to emphasize principles of patient safety and system-wide improvement strategies. The chief resident presents a structured timeline of the case. The conference follows an interactive small group format in which each resident cohort group is assigned specific safety tasks. Chief residents and faculty members facilitate small group activities. The postgraduate year 1 (PGY-1) group conducts an error analysis by defining the medical error and adverse event, and determining whether the medical error caused the adverse event. The PGY-2 group is given a blank Ishikawa fishbone diagram, and residents conduct a root cause analysis with both systems and individual contributors. The PGY-3 group is expected to generate an action plan based on the case, and present a SMART (Specific, Measurable, Attainable, Relevant, Time bound) aim proposal to resident members of the Patient Safety Quality Council (PSQC). The residency program formed the PSQC in 2014 to provide a forum for discussion of patient safety issues and to promote engagement in quality improvement initiatives centered on the clinical environment. Fifteen residents from all PGYs were peer-nominated and recruited to join the council. Council members also included a patient safety officer from the institution, a nurse, a pharmacist, informatics personnel, and various volunteer faculty members. These members are invited to the monthly M&M, and they serve as stakeholders for the generated action plans developed in the M&M conferences. PSQC members discuss the action plans generated from the M&M, and conduct PDSA (plan, do, study, act) cycles at monthly meetings; they also continue to work on pertinent issues after the meetings. At subsequent M&M conferences, the chief resident begins with a follow-up of the projects from the PSQC members.Our M&M conference is modeled after a system that integrates a resident-driven PSQC forum with M&M conferences. This allows for M&M discussions to develop into process improvements and effective action plans. A resident-driven multidisciplinary committee can be a valuable forum where feedback from M&M could be operationalized into action. Moving from M&M discussions to implementing action plans requires involvement of designated champions and administrative staff to help champion these efforts. The M&M and PSQC model have led to several process improvements (table). Our approach shows that the M&M conference can serve as more than a forum for education. Revamping it to focus on action plans may not be sufficient to create high-value process improvements that impact delivery of patient care. We feel that a structured forum with identified stakeholders, such as a patient safety council, has great potential to turn mortality discussions into robust, actionable improvement plans.