Strategies for Quality Improvement Success in Morbidity and Mortality Conferences
CCCF ePoster library. Giesbrecht V. Nov 2, 2016; 150972; 91
Vanessa Giesbrecht
Vanessa Giesbrecht
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Topic: Quality Assurance & Improvement

Strategies for Quality Improvement Success in Morbidity and Mortality Conferences

Giesbrecht, Vanessa1; Boiteau, Paul2; Au, Selena2.
1MD Candidate, Cumming School of Medicine University of Calgary; 2Department of Critical Care Medicine Calgary Zone, Alberta Health Services, Cumming School of Medicine University of Calgary, Calgary, Canada.


Introduction: The Calgary Department of Critical Care Medicine (DCCM) morbidity and mortality conference (MMC) provides a valuable opportunity to review individual patient cases for care structure and processes that may contribute to safety outcomes.  Review of 2212 mortality cases over 5 years identified 148 cases (6.7%) with adverse events that have contributed to major morbidity or mortality.  Recommendations stemming from these cases were directed internally within the DCCM in 40 (26%) cases, with the majority of recommendations lacking goal directed outcomes or assignment of an action item owner for follow-up.  The DCCM has committed to restructuring the MMC to increase its capacity as a tool for quality improvement (QI) and patient safety output.  By September 2017, 12 months after the launch of a revised MMC, the DCCM aims to increase the Patient Safety Grade by 20%.1     

Objectives: This project looked to form practice recommendations for QI based MMCs, summarizing strategies utilized by medical and surgical departments successful in developing patient safety centered MMCs.  Recommendations were tailored to the local DCCM for integration into a revised MMC. 

Methods: We conducted a literature review for strategies employed by surgical and medical departments in the development of productive patient safety centered MMCs.  143 abstracts were screened; 59 articles were reviewed in full by two independent reviewers.  Qualitative analysis included development of a comprehensive list of MMC practice changes made in each article and iterative categorization of changes into strategic themes based on similarity in intention and implementation. This summary report was paired with a local needs assessment comprised of survey, safety leader consultation, and MMC audit to create a revised MMC framework.

Results: We identified six strategic themes of MMC best practices for QI success.  This includes MMC role definition, having a means for detecting adverse events, involving stakeholders, selecting appropriate cases, structuring goal-directed discussion, and tailoring recommendations for success.  Methods we used to adopt these themes included creating a multisite, multidisciplinary MMC with facilitators and online templates to guide systems analysis (Table 1).  A staff education plan has been scheduled for the summer of 2016.  The framework includes a measurement plan for outcome (AHRQ Safety Culture Survey revised to include specific questions on the MMC experience), process (percentage of recommendation completion, and balance (duration of the monthly MMC).1 
Conclusion: The modern patient safety centered MMC shares common themes for best practices that can be adopted by institutions looking to create a venue for analysis of care processes, a platform to launch QI initiatives, and to further develop the culture of safety.  From our needs assessment, staff have highlighted the value of disseminating teaching points after reviews.  This prioritizes our next step to create a forum for the sharing of safety learnings.


1Sorra JS, and Nieva VF. 2004, September. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality.

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