Morbidity and mortality meetings for improved patient care

Prabhaharan Renganathana,*, Venkita S Sureshb

Technical Editor – Kauverian Medical Journal, Kauvery Hospital, Trichy, India

Group Medical Director, Kauvery Hospitals, India

*Correspondence: [email protected] (R. Prabhaharan); [email protected] (Dr. Venkita Suresh)

Introduction

Morbidity and Mortality (M&M) meetings, also referred to as Mortality and Morbidity Audits, are a very necessary component of contemporary hospital medicine. Despite this, there is currently a lack of evidence-based guidance on how they should be conducted [1]. As a result, models of M&M meetings reported in the literature contain considerable variation in terms of structure, processes and outcomes [2]. In 2014, the Clinical Excellence Commission (CEC) published a guideline for the conduct and reporting of M&M meetings. This comprehensive guideline outlines the key principles and features of M&M meetings in all settings.

The objective of this report is to provide actionable, evidence-based recommendations to hospital doctors on how to conduct M&M meetings. In doing so, the aim is to contribute to the continual improvement of patient outcomes, and the continued professional development of medical staff.

Morbidity and Mortality Meeting

M&M meeting is a regular conference held by medical services in hospitals which involves a peer review discussion of issues that occurred during the care of patients, resulting in a complication or death. The primary purpose of the M&M meeting is to allow learning from issues by modifying judgment and clinical decision making, to prevent the repetition of these events, and to improve patient care.

Importantly, the structure and duration of M&M meetings differ between healthcare systems and within healthcare systems. However, M&M meetings consistently provide doctors with a forum to confidently discuss medical complications and adverse events in a non-punitive environment, to improve patient safety [3].

There is debate around whether M&M meetings are fundamentally distinct from other educational and quality assurance interventions, such as  clinical audit, peer-review and incident reporting systems [4]. Authors have argued that quality assurance processes should specifically focus on systems improvement, while M&M meetings should be targeted towards clinical performance improvement [5]. However, there is a growing body of literature to suggest that M&M meetings can be effective tools for highlighting both systems errors and technical/clinical causes of adverse events and mortality [6].

Benefits of an M&M meeting

There is compelling evidence that M&M meetings lead to meaningful improvement in patient outcomes. M&M meetings are also helpful for identifying changes to clinical practice and systems [7]. M&M meetings have been shown to be a useful and effective tool for identifying areas for systems improvement, noting that recommended changes identified in the M&M meeting must be actively initiated and followed-up, for example, through changes to local practice protocols and guidelines and improved clinical practice.

In addition to patient safety, M&M meetings are valuable tools for medical education. Surveys consistently report that surgical and medical staff view structured M&M meetings to be valuable educational tools [8].

Appropriate format of M&M meetings

Meeting format refers to the administration and structure of an M&M meeting. This includes the scope and goals of the meetings, the way in which they are structured (i.e. frequency, location and attendees) and prepared for (i.e. who is responsible for selecting and reviewing cases).

Administrative characteristics of effectively run M&M meetings include:

  1. A written charter or terms of reference, to clearly define the goals of the meeting.
  2. A structured meeting format, to assist in keeping discussions focussed on important issues, and to ensure the quality, consistency and rigor of case presentations. The Situation, Background, Assessment, Recommendation (SBAR) model is a useful tool to improve the quality and consistency of case presentations by doctors of all skill levels.
  3. A structured process for case identification, to improve quality and consistency of reporting of complications to the M&M review process, and ensure case mix is diverse for the educational benefit of participants.
  4. An agenda distributed prior the meeting, to encourage participation by allowing staff to familiarise themselves with the cases and issues before the meeting.
  5. Multidisciplinary involvement, for staff that could benefit from the cases being presented. The entire team involved in the care of a patient that experienced an adverse event can benefit from the discussions at M&M meetings.
  6. A regular schedule. Shorter, more frequent (thus timely) M&M meetings are more engaging, require less preparation, and are easier to fit into busy schedules.
  7. Appointment of dedicated M&M personnel, e.g. departmental M&M coordinators, to take responsibility for the meeting schedule, content and attendance for a defined period.
  8. Use of appropriate tools and software, which may include the use of pre-defined proformas for M&M reporting, electronic record keeping, case presentation and follow-up of initiatives as well as the use of tele-/video-/web-based conferencing to overcome geographical challenges and time restrictions.
  9. Self-nomination of cases, including anonymously, which has been shown to increase the number of safety reports reviewed at an institution.

Appropriate conduct during M&M meetings

The conduct of the meeting refers to the way in which the meeting is carried out, such as who presents cases and how discussion and recommendations are facilitated. Characteristics of effectively run M&M meetings include:

  1. A structured case presentation format, to ensure that case discussions are thoroughly prepared, and kept to a strict time limit.
  2. A focus on systems not individuals, or a central theme, is a useful strategy for identifying areas for improvement in patient care and to facilitate more in-depth and constructive discussion of patient adverse events and medical errors.
  3. A review of near-misses and close-calls, in order to identify and implement policy changes to prevent future error and harms before they occur.
  4. A safe, blame-free environment, to ensure participants respond well. That is when M&M meetings have an emphasis on learning not culpability, they enable dialogue about decisions and outcomes and look for systems error rather than personal error.

Appropriate outcomes of M&M meetings

The outcome of an M&M meeting describes the way in which recommendations for improvements are implemented and followed up. Outcome characteristics of effectively run M&M meetings include:

  1. Recommendations for individual/systems improvement made for each case.
  2. A timeline and follow-up on recommendations for improvement, in order to ensure recommendations identified at M&M meetings are adequately implemented.
  3. A dedicated individual/group to implement recommendations for improvement, and provide regular updates on the progression of their tasks.
  4. Detailed records of M&M outcomes, to allow for review and meaningful follow-up of recommended changes to local practice.

Key challenges to running effective M&M meetings

A number of challenges need to be overcome in order for M&M meetings to meet their desired outcomes, including:

  1. Logistical issues. Key personnel are often absent from M&M meetings due to logistical issues related to other obligations, or the timing or location of the M&M meeting. Video conferencing can be used to help ameliorate some of these issues, and may be particularly helpful in rural settings. However, this requires dedicated infrastructure and resources to conduct effectively. Other alternatives include advanced scheduling of M&M Meetings, 6-12 months in advance, to allow time to overcome scheduling conflicts.
  2. A lack of understanding around the process. Staff should receive formal training in quality improvement methods, in order to ensure the intended aims, processes, and outcomes of M&M meetings are understood by all those involved.
  3. Poor beliefs about the process.  Residents/trainees may view M&M meetings negatively if they have not previously presented or  had an adverse experience at a previous M&M meeting, or if the meeting:
    1. is not organised purposefully
    2. does not follow a structured format;
    3. does not include follow-up of suggested changes to local practice;
    4. does not provide information before the meeting;
    5. does not provide a fair assessment of the individual(s) involved in the reported issue, or
    6. is not conducted in a blame-free environment.
  4. This guideline has provided many recommendations to address these challenges, and suggests hospitals to encourage residents/ trainees to become actively involved in the M&M process in order to stimulate engagement.
  5. Heterogeneity in case presentation and evaluation. Peer-review, even after comprehensive discussion in a format such as an M&M meeting, is often heterogeneous. Structured formats are an effective way of ensuring that the quality of case presentation is consistent, and can help guide discussions. However, it is important that standard templates do not systematically exclude particular viewpoints. Using a dedicated facilitator to mediate discussions can help ensure discussions follow a defined structure, while encouraging the input from attending staff.
  6. Lack of attendance. Often multidisciplinary team members that may benefit from attendance may not attend. Consideration should be given to factors that facilitate attendance such as an attendance register, CPD requirements, protected time, no scheduled surgery on M&M days. It is strongly advocated that all  docotrs directly responsible for patient care and teaching be present at all M&M meetings unless illness will not allow. The decision making afforded by attendance and discussion is effective for improving care delivery and clarifying best practice.
  7. Medico-legal concerns. The documentation presented and resultant from M&M meetings should be considered within the medico-legal environment in which all healthcare exists; however, this should not preclude the accurate and effective learning presented in these meetings. As quality improvement activities, the meetings may be privileged depending on the jurisdiction.

References

  1. Bindroo S, Saraf R. Surgical mortality audit-lessons learned in a developing nation. Intern Surg. 2015;100(6):1026-32.
  2. Clarke DL, Furlong H, Laing GL, et al. Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital. South African J Surg. 2013;51(4):122-6.
  3. Fuangworawong P, LaGrone LN, Chadbunchachai W, Sornsrivichai V, Mock CN, Vavilala MS. Assessment of trauma quality improvement activities at public hospitals in Thailand. Intern J Surg. 2016;33:88-95.
  4. Schwarz D, Schwarz R, Gauchan B, et al. Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Qual Safety. 2011;20(12):1082-8.
  5. Bal G, Sellier E, Tchouda SD, et al. Improving quality of care and patient safety through morbidity and mortality conferences. J Healthcare Qual: Off Publ Nat Assoc Healthcare Qual. 2014;36(1):29-36.
  6. Travaglia J, Debono D. Mortality and morbidity reviews: a comprehensive review of the literature. Sydney, Australia: The Centre for Clinical Governance Research in Health, 2009.
  7. Batthish M, Tse SM, Feldman BM, et al. Trying to improve care: the Morbidity and Mortality Conference in a division of rheumatology. J Rheumatol. 2014;41(12):2452-8.
  8. Cromeens B, Brilli R, Kurtovic K, et al. Implementation of a pediatric surgical quality improvement (QI)-driven M&M conference. J Pediatric Surg. 2016;51(1):137-42.

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